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Does Blue Cross Blue Shield Cover Entyvio: Coverage Explained

Does Blue Cross Blue Shield Cover Entyvio: Coverage Explained

Are you wondering, does Blue Cross Blue Shield cover Entyvio? If you’ve been considering Entyvio as a treatment option for Crohn’s disease or ulcerative colitis, navigating insurance coverage can be a critical factor in your decision-making process. Understanding the specifics of your Blue Cross Blue Shield plan and how it relates to Entyvio coverage is essential to ensure access to the treatment you need.

Let’s delve into the details to shed light on this important question.

Understanding Entyvio Coverage with Blue Cross Blue Shield

Blue Cross Blue Shield (BCBS) coverage for Entyvio depends on several factors, including the specific plan and the state where the member resides. Here’s what you need to know:

  1. Approval for Coverage: Before starting treatment with Entyvio, your health insurance provider must approve your coverage. The process involves the following steps:

    • Benefits Verification: Your doctor’s office will work with your insurance company to determine if Entyvio is covered.
    • Prior Authorization: Your doctor’s office will submit a request to your health insurance company to get approval for you to start treatment with Entyvio.
  2. EntyvioConnect: While waiting for approval, consider signing up for EntyvioConnect. This program provides financial and insurance support. You can explore eligibility for the Entyvio co-pay program, which may help you save on out-of-pocket costs. With this program, eligible patients may pay as little as $5 per dose.

Remember that coverage details can vary based on your specific plan, so it’s essential to check with your insurance provider directly to confirm your coverage and eligibility for Entyvio. If you have any questions or need assistance, feel free to reach out to EntyvioConnect.

Important Safety Information:

  • Do not receive Entyvio if you’ve had an allergic reaction to it or any of its ingredients.
  • Serious side effects may include infusion-related allergic reactions and infections.
  • Progressive Multifocal Leukoencephalopathy (PML) is a rare, serious brain infection that can occur in people with weakened immune systems. While unlikely with Entyvio, the risk cannot be ruled out. Seek medical attention if you experience symptoms like confusion, balance problems, vision changes, or weakness.

Blue Cross Blue Shield Health Insurance Coverage Overview

Blue Cross Blue Shield (BCBS) provides comprehensive health insurance coverage. Here are some details:

  1. Member Services:

    • You can access your benefits, view your plan details, and perform various tasks such as changing your coverage, estimating medical procedure costs, filing or checking claims, and replacing your member ID card. Use the interactive search on the BCBS Member Services page to find your local BCBS company’s website.
    • BCBS members also enjoy exclusive discounts on health and wellness products and services through Blue365®.
  2. Summary of Benefits and Coverage (SBC):

    • BCBS of Massachusetts provides an SBC with online access to the corresponding coverage policy for fully insured members and accounts. To view your coverage policy document, select the size of your employer group and then choose the plan name listed at the top of your SBC. You can find more information on the Coverage Benefits Summary page.
  3. Understanding Your Coverage:

    • If you’re using Blue Cross Mobile, you can explore your benefits by hitting the “Coverage” button in the navigational dashboard. Search benefits by keyword, prescription drug name, DIN, or dental procedure code.
  4. Global Coverage:

    • BCBS companies offer a comprehensive suite of international products and services for people who live, work, and travel internationally. Whether you’re a short-term traveler or a long-term expatriate, BCBS provides quality care wherever you need it. Learn more about BCBS Global.

Remember that BCBS is committed to providing reliable healthcare coverage, both domestically and globally. If you have specific questions about your coverage, I recommend reaching out to your local BCBS company for personalized assistance.

A chart summarizing the deductible, coinsurance, and out-of-pocket maximums for in-network and out-of-network services, as well as the annual deductible and coinsurance for in-network services.

IMG Source: yumpu.com


Understanding Entyvio Mechanism of Action

Entyvio (vedolizumab) is a prescription drug used to treat Crohn’s disease and ulcerative colitis. Let me explain how it works:

  1. Mechanism of Action:

    • Entyvio is a biologic medication containing the active ingredient vedolizumab.
    • It selectively targets the gut by blocking a specific protein.
    • This protein is responsible for signaling certain white blood cells that contribute to inflammation in the gastrointestinal (GI) tract.
    • By inhibiting these white blood cells, Entyvio helps reduce inflammation in the gut.
  2. Administration:

    • Entyvio is available as an injection.
    • It can be administered either under the skin or slowly into a vein.
    • The drug specifically acts in the gut, which minimizes system-wide immunosuppression.
  3. Common Side Effects:

    • Mild side effects of Entyvio include:
      • Headache
      • Runny nose
      • Nausea
      • Fatigue
      • Fever
      • Upper respiratory infections (such as a cold)
      • Back pain
      • Cough
      • Skin reactions (rash or itchiness)
      • Injection site reactions (swelling or bruising, if injected under the skin)
      • Joint pain
    • Serious side effects are less common but may include:
      • Infusion reactions (allergic reactions after receiving an infusion)
      • Liver problems (including liver damage)
      • Serious infections (such as tuberculosis, giardiasis, or cytomegaloviral colitis) .

In summary, Entyvio works by blocking the inflammatory response

Illustration of a lymphocyte with annotations of endothelial cells, Mac-1, and β4 integrin.

IMG Source: gstatic.com


Coverage Guidelines for Vedolizumab (Entyvio) under Blue Cross Blue Shield Plans

Here are the coverage guidelines for Vedolizumab (Entyvio) under Blue Cross Blue Shield (BCBS) plans:

  1. Description:

    • Vedolizumab (Entyvio) is a monoclonal antibody and integrin receptor antagonist used for treating moderately to severely active Crohn’s disease (CD) and ulcerative colitis (UC) in adults.
    • It works by binding to the α4β7 integrin receptor, inhibiting its interaction with mucosal addressin cell adhesion molecule-1 (MAdCAM-1), and reducing inflammation in the gastrointestinal tissue associated with UC/CD.
  2. Coverage Criteria:

    • Coverage is subject to the specific terms of the member’s benefit plan.
    • Federal Employee Program (FEP) members should check with their Retail Pharmacy Program to determine if prior approval is required.
    • Vedolizumab (Entyvio) may be considered medically necessary when an individual meets ANY ONE of the following criteria:
      • Crohn’s Disease (CD):
        • Diagnosis of moderately to severely active CD.
        • ONE of the following:
          • The individual has been treated with vedolizumab (Entyvio) within the past 90 days.
          • The prescriber states that the individual has been treated with vedolizumab (Entyvio) within the past 90 days AND is at risk if therapy is changed.
        • BOTH of the following:
          • The individual is 18 years of age or older OR the prescriber supports using vedolizumab (Entyvio) for the individual’s age.
          • ONE of the following:
            • Inadequate response to one (1) conventional agent (e.g., 6-mercaptopurine, azathioprine, corticosteroids) used in CD treatment for at least three (3) months.
            • Intolerance or hypersensitivity to one (1) conventional agent used in CD treatment.
            • FDA-labeled contraindication to ALL conventional agents used in CD treatment.
            • Medication history indicates use of another biologic immunomodulator agent supported for CD treatment.
          • The prescriber is a specialist in the area of the individual’s diagnosis or has consulted with a specialist.
          • The individual has been previously approved for vedolizumab (Entyvio) through BCBS precertification process and has had clinical benefit with it.
  3. Pharmacy Policies:

    • The intravenous formulation of vedolizumab (Entyvio) may be covered under the medical benefit; refer to pharmacy policies for coverage of the subcutaneous formulation.

For more detailed information, you can refer to the official BCBS policy document here.

A table listing drugs requiring prior authorization, organized by therapeutic category.

IMG Source: yumpu.com


Consider Alternative Treatment Options to Entyvio

When considering alternative treatment options to Entyvio (vedolizumab), it’s essential to consult with a healthcare professional. Here are some alternatives that may be worth discussing:

  1. Mesalamine: This medication falls under the class of 5-aminosalicylates and is used to manage inflammatory bowel diseases like ulcerative colitis. It comes in various forms, including oral capsules, enemas, and suppositories. Mesalamine has generally positive reviews from users.

  2. Stelara (ustekinumab): Stelara is an immunosuppressant that targets specific inflammatory cytokines (IL-12 and IL-23). It has been effective in treating chronic inflammation associated with conditions like Crohn’s disease and psoriasis.

  3. Tofacitinib (Xeljanz): A janus kinase inhibitor, tofacitinib is an alternative for treating ulcerative colitis. It works by modulating the immune response and reducing inflammation.

  4. TNF-alpha inhibitors: These include medications like adalimumab (Humira), golimumab (Simponi), and infliximab (Remicade). They are commonly used for various inflammatory conditions, including Crohn’s disease and rheumatoid arthritis.

  5. Alosetron and Eluxadoline: These are options for managing irritable bowel syndrome. Alosetron helps relax the colon, while eluxadoline treats diarrhea.

  6. Rifaximin: An antibiotic that limits bacterial growth in the intestines, it can be useful in certain cases.

  7. Lubiprostone and Linaclotide: These alternatives increase fluid secretion in the intestine and may be helpful for specific gastrointestinal conditions.

Remember that individual responses to medications can vary, and what works best depends on the specific diagnosis, severity of symptoms, and other factors. Always consult your doctor to determine the most suitable treatment plan for your condition.

A doctor is talking to a patient about Crohns disease. They are discussing ways to manage the disease, such as staying hydrated, eating small meals, quitting smoking, exercising, and attending a support group.

IMG Source: verywellhealth.com


As you explore the realm of healthcare coverage and treatment options, the question of does Blue Cross Blue Shield cover Entyvio may weigh heavily on your mind. With the intricacies of insurance plans and medication approval processes, seeking clarity on your coverage for Entyvio is paramount. Remember, each Blue Cross Blue Shield plan may have its own guidelines and requirements, so reaching out to your insurance provider directly for personalized assistance is crucial.

Whether it’s understanding coverage criteria or exploring alternative treatment options, staying informed and proactive in your healthcare journey can lead to better outcomes. Feel empowered to advocate for yourself and make informed decisions regarding your health and treatment choices. Health and wellness are valuable assets, and navigating the healthcare landscape with knowledge and support can pave the way to a brighter, healthier future.

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