Does Blue Shield of California Cover Liraglutide (Saxenda)

Discover if Blue Shield of California covers Liraglutide (Saxenda), reasons for denial, coverage tips, costs without insurance, and FAQs in this comprehensive guide.
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Coverage for Liraglutide (Saxenda)

 

  • Blue Shield of California typically covers Saxenda under specific conditions where it is medically necessary for weight management in patients who are overweight with weight-related comorbidities or obese.
  •  

  • Medical necessity must be documented by a healthcare provider, including evidence of a failed attempt at weight loss through diet and exercise.
  •  

  • Authorization and coverage may require detailed medical records and sometimes a pre-authorization request from your physician.
  •  

  • Eligibility criteria often include a Body Mass Index (BMI) requirement, usually a BMI of 30 or higher, or 27 with associated conditions like hypertension, type 2 diabetes, or dyslipidemia.
  •  

 

Steps for Obtaining Coverage

 

  • Consult your healthcare provider to evaluate if Saxenda is right for you based on your medical profile.
  •  

  • Your provider may need to submit a prior authorization request to Blue Shield of California explaining medical necessity.
  •  

  • Review your specific plan details or contact customer service to understand any plan-specific criteria or documentation requirements.
  •  

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Curex is poised to revolutionize the way allergies are treated in America, expanding access to clinical care and treatments that can meaningfully improve patients quality of life.

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At Curex, our mission is to help people improve their health and quality of life by understanding their allergies and treating them at their source.We provide more than individualized prescription treatments; we provide individualized care.

Jill Hamburg, PA - C

Immunotherapy made simple.  We enable patients to receive personalized allergy care on their own time. No more waiting rooms.

Dr. Chet Tharpe, Medical Director

Curex has set the standard for the virtual allergy experience. From the comfort of their home, patients nationwide are able to receive a personalized treatment plan from an experienced clinician, aimed at treating the source of their allergies, not just the symptoms.

Kayla Mardaga, NP

Curex offers convenient at-home allergy testing options. Our goal is to determine if a patient would benefit from immunotherapy and then customize a treatment plan that can reduce both the symptoms and the reliance on allergy medications.

How to Get Liraglutide (Saxenda) Coverage with Blue Shield of California

 

Understand Your Insurance Plan

 

  • Review your Blue Shield of California policy to determine your coverage benefits related to weight management and prescription medication.
  •  

  • Check if there are any specific exclusions or limitations associated with Saxenda (Liraglutide) in your plan.

 

Consult with Your Healthcare Provider

 

  • Speak with your doctor about your weight management needs and why Saxenda is a suitable option for you.
  •  

  • Ensure your healthcare provider is willing to provide medical documentation to support your necessity for Saxenda, if required.

 

Contact Blue Shield of California

 

  • Reach out to Blue Shield's customer service to inquire about their process for covering Saxenda.
  •  

  • Ask if pre-authorization is necessary and what specific criteria need to be met for coverage.

 

Submit a Pre-authorization Request

 

  • Work with your healthcare provider to compile the necessary documentation and complete any pre-authorization forms.
  •  

  • Submit the pre-authorization request to Blue Shield of California as per their guidelines.

 

Follow Up on Your Request

 

  • Monitor the status of your pre-authorization request by regularly contacting Blue Shield of California.
  •  

  • Be prepared to provide additional information or documentation if requested by the insurance provider.

 

Review the Determination

 

  • Once you receive a determination from Blue Shield, review it carefully to understand their decision.
  •  

  • If approved, confirm the details of coverage, including any copayments or plan limits.

 

Appeal If Necessary

 

  • If your pre-authorization request is denied, review the reason for denial, and gather any additional information that could support your case.
  •  

  • Submit an appeal to Blue Shield of California, addressing the reasons for denial and emphasizing medical necessity.

 

Pharmacy Coordination

 

  • Once approved, work with your pharmacy to ensure they have the insurance information needed to process Saxenda under your coverage.
  •  

  • Ensure the pharmacy confirms your financial responsibility before dispensing the medication.

 

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FAQs

Does Blue Shield of California Cover Liraglutide (Saxenda)

Discover if Blue Shield of California covers Liraglutide (Saxenda), reasons for denial, coverage tips, costs without insurance, and FAQs in this comprehensive guide.
Curex allergy drops unboxing

Is Liraglutide (Saxenda) Covered by Blue Shield of California

 

Coverage for Liraglutide (Saxenda)

 

  • Blue Shield of California typically covers Saxenda under specific conditions where it is medically necessary for weight management in patients who are overweight with weight-related comorbidities or obese.
  •  

  • Medical necessity must be documented by a healthcare provider, including evidence of a failed attempt at weight loss through diet and exercise.
  •  

  • Authorization and coverage may require detailed medical records and sometimes a pre-authorization request from your physician.
  •  

  • Eligibility criteria often include a Body Mass Index (BMI) requirement, usually a BMI of 30 or higher, or 27 with associated conditions like hypertension, type 2 diabetes, or dyslipidemia.
  •  

 

Steps for Obtaining Coverage

 

  • Consult your healthcare provider to evaluate if Saxenda is right for you based on your medical profile.
  •  

  • Your provider may need to submit a prior authorization request to Blue Shield of California explaining medical necessity.
  •  

  • Review your specific plan details or contact customer service to understand any plan-specific criteria or documentation requirements.
  •  

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Blue Shield of California's Approved Criteria for Liraglutide (Saxenda) Coverage

 

Eligibility Criteria for Liraglutide (Saxenda) Coverage

 

  • Patient must be at least 18 years old.
  •  

  • Liraglutide is prescribed for the treatment of chronic weight management.
  •  

  • Patient must have a body mass index (BMI) of 30 kg/m² or greater, or a BMI of 27 kg/m² or greater with at least one weight-related comorbidity (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia).
  •  

  • There must be a documented history of unsuccessful weight loss with at least one prior weight management program, which may include through diet and exercise modifications.
  •  

  • Physician attestation that the patient will continue an ongoing lifestyle intervention program (e.g., reduced calorie diet and increased physical activity) in conjunction with Liraglutide therapy.

 

Continuation of Liraglutide (Saxenda) Coverage

 

  • Initial prescription is limited to a 16-week trial period. For continued treatment approval, the patient must demonstrate at least a 4% weight loss from baseline by the end of this trial period.
  •  

  • Treatment plan must be re-evaluated periodically by the prescribing healthcare provider to ensure the patient is benefiting from continued use.
  •  

  • Documentation of ongoing participation in lifestyle modification programs must be provided at the time of continued coverage request.

 

Prescribing and Dosage Guidelines

 

  • Liraglutide should be prescribed by healthcare providers specializing in weight management or endocrinology.
  •  

  • Dosage must follow the FDA-approved labeling guidelines, starting at a dose of 0.6 mg per day and gradually increasing to a target dose of 3 mg per day, as tolerated.

 

Why Blue Shield of California Might Deny Liraglutide (Saxenda) Coverage

 

Reasons for Denial of Liraglutide (Saxenda) Coverage by Blue Shield of California

 

  • Liraglutide (Saxenda) may be denied if the patient does not meet the specific weight-related diagnoses. Blue Shield of California typically requires the individual to be classified as obese, defined by a body mass index (BMI) of at least 30 kg/m², or overweight with a BMI of at least 27 kg/m² accompanied by a weight-related comorbidity. Failure to meet these criteria can result in a denial.
  •  

  • Insurance coverage for Liraglutide (Saxenda) may not be approved if there is insufficient documentation of prior weight loss attempts. Blue Shield of California might require evidence of previous attempts at weight loss through diet and exercise or other weight management programs before covering the medication.
  •  

  • Non-compliance with other medical therapies might lead to denial. If there is documentation showing that the patient has not adhered to prescribed alternative treatments or lifestyle changes, coverage may be refused.
  •  

  • Certain age restrictions may apply. If the patient falls out of the specified age range for Saxenda usage as determined by Blue Shield of California's policy, coverage could be denied.
  •  

  • Coverage may be denied if the prescription of Liraglutide (Saxenda) is for a use not approved by the FDA or considered outside the scope of normal practice guidelines, such as non-weight-related conditions.
  •  

  • Failure to receive a prior authorization when required can lead to denial. Blue Shield of California may require prior authorization for high-cost medications like Saxenda, and without this prior approval, coverage can be denied.
  •  

  • Possession of contraindicated medical conditions that are outlined in Blue Shield of California's policy could result in denial of coverage. For instance, a history of MTC (medullary thyroid carcinoma) or MEN 2 (multiple endocrine neoplasia syndrome type 2) could preclude coverage.
  •  

 

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How Much Does Liraglutide (Saxenda) Cost without Insurance?

 

Liraglutide (Saxenda) Cost without Insurance

 

  • The cost of Liraglutide, commonly marketed under the brand name Saxenda, can vary based on location and pharmacy, but it typically ranges between $1,300 and $1,500 for a 30-day supply, which includes five injectable pens.
  •  

  • Prices can fluctuate due to factors like pharmacy pricing policies, manufacturer offers, and location. It is advisable to compare prices from various pharmacies or online sources.
  •  

  • Pharmacies may offer discount programs or coupons that could reduce the out-of-pocket cost. It's a good idea to inquire about available savings options.
  •  

  • Some online pharmacy platforms may provide competitive pricing and discounts, so checking these can be beneficial for finding better deals.
  •  

  • Prescription assistance programs, sometimes offered by the manufacturer, can provide help for individuals who meet certain income or insurance criteria. Exploring these options might also lead to cost savings.

 

Our team is here to help!

Dr. Neeta Ogden, MD

Curex is poised to revolutionize the way allergies are treated in America, expanding access to clinical care and treatments that can meaningfully improve patients quality of life.

Dr. Ravi Patel, VP Telemedicine

At Curex, our mission is to help people improve their health and quality of life by understanding their allergies and treating them at their source.We provide more than individualized prescription treatments; we provide individualized care.

Jill Hamburg, PA - C

Immunotherapy made simple.  We enable patients to receive personalized allergy care on their own time. No more waiting rooms.

Dr. Chet Tharpe, Medical Director

Curex has set the standard for the virtual allergy experience. From the comfort of their home, patients nationwide are able to receive a personalized treatment plan from an experienced clinician, aimed at treating the source of their allergies, not just the symptoms.

Kayla Mardaga, NP

Curex offers convenient at-home allergy testing options. Our goal is to determine if a patient would benefit from immunotherapy and then customize a treatment plan that can reduce both the symptoms and the reliance on allergy medications.

How to Get Liraglutide (Saxenda) Coverage with Blue Shield of California

 

Understand Your Insurance Plan

 

  • Review your Blue Shield of California policy to determine your coverage benefits related to weight management and prescription medication.
  •  

  • Check if there are any specific exclusions or limitations associated with Saxenda (Liraglutide) in your plan.

 

Consult with Your Healthcare Provider

 

  • Speak with your doctor about your weight management needs and why Saxenda is a suitable option for you.
  •  

  • Ensure your healthcare provider is willing to provide medical documentation to support your necessity for Saxenda, if required.

 

Contact Blue Shield of California

 

  • Reach out to Blue Shield's customer service to inquire about their process for covering Saxenda.
  •  

  • Ask if pre-authorization is necessary and what specific criteria need to be met for coverage.

 

Submit a Pre-authorization Request

 

  • Work with your healthcare provider to compile the necessary documentation and complete any pre-authorization forms.
  •  

  • Submit the pre-authorization request to Blue Shield of California as per their guidelines.

 

Follow Up on Your Request

 

  • Monitor the status of your pre-authorization request by regularly contacting Blue Shield of California.
  •  

  • Be prepared to provide additional information or documentation if requested by the insurance provider.

 

Review the Determination

 

  • Once you receive a determination from Blue Shield, review it carefully to understand their decision.
  •  

  • If approved, confirm the details of coverage, including any copayments or plan limits.

 

Appeal If Necessary

 

  • If your pre-authorization request is denied, review the reason for denial, and gather any additional information that could support your case.
  •  

  • Submit an appeal to Blue Shield of California, addressing the reasons for denial and emphasizing medical necessity.

 

Pharmacy Coordination

 

  • Once approved, work with your pharmacy to ensure they have the insurance information needed to process Saxenda under your coverage.
  •  

  • Ensure the pharmacy confirms your financial responsibility before dispensing the medication.

 

Premium Medication you can trust

Our weight loss medication is delivered straight to your doorstep from a state-licensed pharmacy within our reliable network, ensuring you receive your medication when you need it.

Each pharmacy in our network undergoes rigorous third-party testing through FDA and DEA certified labs. These tests focus on four key elements, ensuring both safety and efficacy for our treatments.

Liraglutide (Saxenda) FAQ

How much weight can you lose with Saxenda?

 

Weight Loss with Saxenda

 

  • Clinical trials show Saxenda users can lose an average of 5-10% of their initial body weight over 56 weeks.
  •  

  • Weight loss can vary depending on factors such as initial weight, diet, and physical activity.
  •  

  • Combining Saxenda with a reduced-calorie diet and increased physical activity enhances results.
  •  

  • It's important to monitor progress and consult with a healthcare provider to tailor the plan to individual needs.
  •  

  • Results are not guaranteed, and lifestyle changes significantly influence effectiveness.

What are the side effects of Liraglutide?

 

Common Side Effects

 

  • Nausea, particularly when starting treatment.
  • Vomiting or diarrhea, which can lead to dehydration.
  • Reduced appetite, a desired effect for weight management.
  • Headaches and dizziness, usually mild to moderate.

 

Serious Side Effects

 

  • Severe abdominal pain, signaling possible pancreatitis.
  • Symptoms of thyroid tumors, such as neck swelling or difficulty swallowing.
  • Serious allergic reactions, including hives or breath difficulty.
  • Elevated heart rate or palpitations.

 

Recommendations

 

  • Alert healthcare providers about any side effects.
  • Hydrate well to minimize dehydration from gastrointestinal effects.
  • Monitor blood sugar if diabetic, as levels may change.

 

How does Saxenda work for weight loss?

 

Mechanism of Action

 

  • Saxenda (liraglutide) is a GLP-1 receptor agonist. It mimics the action of the glucagon-like peptide-1, a hormone involved in appetite regulation.
  •  

  • It enhances insulin secretion and delays gastric emptying, promoting a feeling of fullness.

 

Appetite Suppression

 

  • Saxenda targets areas of the brain that control hunger, reducing appetite and calorie intake.
  •  

  • This helps in forming healthier eating habits and better portion control.

 

Additional Benefits

 

  • Besides weight loss, it assists in improving glycemic control for type 2 diabetes patients.
  •  

  • May lead to reductions in waist circumference and improvements in cardiovascular measures.

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Initial Dosage

Your initial medication and dosage are carefully determined by doctors, taking into account your unique health profile. This ensures a personalized and safe treatment plan tailored to your specific needs.

Titration

We gradually adjust your dosage to reach the optimal therapeutic level, ensuring maximum effectiveness while minimizing potential side effects.

Additional Treatments

Our providers may also recommend medications such as metformin or supplements such as vitamin B12. We recognize the importance of managing side effects, so your care plan may include medication to alleviate them.

Got questions? We have answers.

Do your plans include prescriptions and medications?

Curex plans cover everything from reviewing your medical intake to providing prescription medications, with free shipping included. There are no extra or hidden charges. Prescriptions are issued only after a medical provider reviews your information to confirm that the medication is suitable for you. Our service includes continuous support and regular follow-ups to ensure your treatment stays on track.

Our clinicians may order labs and additional medications for you, which would not be covered by the plan but for which you can use your insurance.

Please note: Compounded medications are tailored to individual needs or used in case of shortages, but they are not FDA-approved for safety or effectiveness. A prescription is required. Results may vary from person to person.

What medications do your providers prescribe?

We prioritize a personalized approach to your health. If your medical provider prescribes medication, options may include GLP-1 treatments such as compounded semaglutide (the active ingredient in Wegovy®* and Ozempic®*). Our providers prescribe only combination treatments not available at your local pharmacy that may include vitamin B12, etc. to help you achieve your goals faster.

Depending on your treatment goals, other medications such as metformin may also be considered. We recognize the importance of managing side effects, so your care plan might include medication to ease symptoms like nausea. Your well-being is always our top priority!

Please note that compounded medications are customized to meet individual patient needs and are not FDA-approved for safety or effectiveness. A prescription is necessary. Results may vary from person to person.

Curex and its pharmacy partners do not have any association with Novo Nordisk.

Will I be prescribed semaglutide if I sign up?

Your health journey is unique, and we tailor our care to match. Any prescriptions, including semaglutide, will be based on the expert assessment of the medical provider matched with you through our platform. You can trust that your treatment plan will be personalized to fit your specific needs. And if semaglutide is not prescribed, we will provide a full refund.

What is compounded medication?

Compounding involves creating customized medications to meet the specific needs of individual patients. For instance, a patient may require a liquid version of a medication that is only available in tablet form. Pharmacies can also compound medications using FDA-approved drugs that are on the FDA’s shortage list.

These compounded medications are made by state-licensed pharmacies that follow both federal and state regulations, including quality standards. However, when compounded in accordance with these laws, these medications are not subject to FDA approval and are not evaluated for safety or effectiveness.

Is compounded medication the same as generic medication?

Compounded medications differ from generic drugs. Generics require FDA approval by demonstrating bio-equivalence to the brand-name drug. In contrast, compounded medications are not FDA-approved. They are made based on a personalized prescription that may not be commercially available elsewhere or when a drug appears on the FDA’s shortage list. Compounding pharmacies must have the proper licensed facilities and comply with state and federal regulations before dispensing these medications.

Is insurance required?

No, Curex doesn’t require insurance. We offer clear and simple pricing, along with affordable medication options, making it easy and accessible to take care of your health.

Can I pay with an FSA or HSA card?

Yes! You can pay with your HSA or FSA card.

How much does treatment cost?

Semaglutide Injections:

Prices for semaglutide start at only $149 per month for weekly doses of 0.25mg and 0.5mg. You can cancel anytime. Some people experience weight loss at these doses and higher doses aren't advisable due to a higher risk of side effects. If you need a higher dose to achieve your weight loss goals, we offer higher-dose plans for 1mg, 1.7mg and 2.4mg of semaglutide for an additional $50 per month for each plan.

Tirzepatide Injections:

Prices for tirzepatide start at only $249 per month for weekly doses of 2.5mg and 5mg of tirzepatide.You can cancel anytime. Some people experience weight loss at these doses and higher doses aren't advisable due to a higher risk of side effects. If you need a higher dose to achieve your weight loss goals, we offer higher-dose plans for 7.5mg, 10mg and 12.5mg of tirzepatide for an additional $100 per month for each plan.

Semaglutide Tablets:

Prices for semaglutide tablets start at only $149 per month for daily doses of 2mg. You can cancel anytime. Some people experience weight loss at this dose and higher doses aren't advisable due to a higher risk of side effects. If you need a higher dose to achieve your weight loss goals, we offer higher-dose plans for 4mg and 8mg of semaglutide daily for an additional $50 per month for each plan.

Tirzepatide Tablets:

Prices for tirzepatide start at only $199 per month for daily dosees of 3mg of tirzepatide. You can cancel anytime. Some people experience weight loss at these doses and higher doses aren't advisable due to a higher risk of side effects. If you need a higher dose to achieve your weight loss goals, we offer higher-dose plans for 6mg and 12 mg of tirzepatide daily for an additional $100 per month for each plan.

Can you prescribe Ozempic®* or Wegovy®*?

Our providers focus on personalized medications and dosages that aren’t commercially available at your local pharmacy. While we don’t prescribe Ozempic®* or Wegovy®* directly, we may prescribe treatments containing the same active ingredient. These medications are specially compounded for you by a licensed pharmacy to meet your specific needs.

Are video visits with a provider required?

Our providers will review your information 100% online. Depending on where you live and the specifics of your medical history, our providers may require you to have a video visit or asynchronous visit via text message. If prescribed, you’ll get unlimited online access to message your provider as needed for follow-ups, adjustments, and answers to your questions.

What states do you serve?

Currently, we do not serve Arkansas, Connecticut, and New Mexico. However, we are always working to expand our reach, so stay in touch with us at hi@getcurex.com.

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