Does Blue Shield of California Cover Semaglutide (Wegovy)

Explore if Blue Shield of California covers Semaglutide (Wegovy), reasons for denial, costs without insurance, and tips for obtaining coverage.
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Coverage for Semaglutide (Wegovy)

 

  • Blue Shield of California may cover Semaglutide (Wegovy) for weight management under certain plans. Coverage typically requires meeting specific clinical criteria.
  •  

  • Patients generally need a Body Mass Index (BMI) of 30 or higher, or BMI of 27 or higher with related conditions such as hypertension or diabetes.

 

Basic Rules and Criteria

 

  • Pre-authorization is often required, meaning your healthcare provider must submit a request to Blue Shield to determine if the medication will be covered.
  •  

  • The request typically needs to demonstrate that other weight-loss treatments have been ineffective.
  •  

  • Prescription coverage may also depend on the specific benefits of your health plan; reviewing your plan's formulary is recommended for detailed benefits information.

 

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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.

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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 Semaglutide (Wegovy) Coverage with Blue Shield of California

 

Verify Your Coverage Plan

 

  • Log into your Blue Shield of California online account to review your specific health plan details.
  •  

  • Check your Summary of Benefits and Coverage document to see if prescription medications like Wegovy are covered under your current plan.
  •  

  • Contact Blue Shield’s customer service directly to inquire if Semaglutide (Wegovy) is included in your plan and confirm any specifics regarding it.

 

Consult with Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss your eligibility for Semaglutide (Wegovy).
  •  

  • Ensure your doctor is aware that this medication needs to be covered by insurance and is ready to provide any necessary documentation.
  •  

  • Ask your healthcare provider to write a prescription for Wegovy if they deem it appropriate for your health needs.

 

Pre-authorization Request

 

  • Work with your healthcare provider’s office to submit a pre-authorization request to Blue Shield of California. This process may involve providing medical records or other documentation justifying the need for Wegovy.
  •  

  • Ensure all necessary forms and documentation are completed accurately to avoid delays in processing.

 

Follow Up with Insurance

 

  • Contact Blue Shield to confirm receipt of the pre-authorization request and inquire about the expected timeline for a decision.
  •  

  • Check your Blue Shield account or contact customer service for updates on your pre-authorization status.
  •  

  • Be prepared to provide additional documentation or clarification if Blue Shield requests more information.

 

Appeal If Necessary

 

  • If your initial request is denied, review the denial letter carefully to understand the reasons behind the decision.
  •  

  • Work with your healthcare provider to gather any additional information that might strengthen your case for coverage.
  •  

  • Submit an appeal to Blue Shield following their specified procedures, providing all necessary documentation to support your request.

 

Continual Monitoring and Communication

 

  • After approval, ensure that your pharmacy receives the prescription authorization from Blue Shield and that Wegovy is available for you to obtain.
  •  

  • Stay in contact with both your healthcare provider and Blue Shield to ensure any future renewals or additional authorizations are handled promptly.
  •  

  • Keep records of all communications with Blue Shield and your healthcare provider related to your Wegovy coverage.

 

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FAQs

Does Blue Shield of California Cover Semaglutide (Wegovy)

Explore if Blue Shield of California covers Semaglutide (Wegovy), reasons for denial, costs without insurance, and tips for obtaining coverage.
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Is Semaglutide (Wegovy) Covered by Blue Shield of California

 

Coverage for Semaglutide (Wegovy)

 

  • Blue Shield of California may cover Semaglutide (Wegovy) for weight management under certain plans. Coverage typically requires meeting specific clinical criteria.
  •  

  • Patients generally need a Body Mass Index (BMI) of 30 or higher, or BMI of 27 or higher with related conditions such as hypertension or diabetes.

 

Basic Rules and Criteria

 

  • Pre-authorization is often required, meaning your healthcare provider must submit a request to Blue Shield to determine if the medication will be covered.
  •  

  • The request typically needs to demonstrate that other weight-loss treatments have been ineffective.
  •  

  • Prescription coverage may also depend on the specific benefits of your health plan; reviewing your plan's formulary is recommended for detailed benefits information.

 

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Blue Shield of California's Approved Criteria for Semaglutide (Wegovy) Coverage

 

Eligibility Criteria for Semaglutide (Wegovy) Coverage

 

  • Patient must be at least 18 years old.
  •  

  • Patient should have a documented diagnosis of obesity, which is defined as a body mass index (BMI) of 30 kg/m² or greater.
  •  

  • Alternatively, patient may qualify with a BMI of 27 kg/m² or greater if there are additional weight-related comorbid conditions such as hypertension, type 2 diabetes, or dyslipidemia.

 

Documentation Requirements

 

  • Provide medical records with current BMI documentation.
  •  

  • Include history of previous weight management treatments and outcomes.
  •  

  • Submit details of any relevant comorbid conditions that justify the use of Semaglutide (Wegovy).

 

Prior Authorization Process

 

  • Secure a prior authorization from Blue Shield of California before the prescription of Semaglutide (Wegovy).
  •  

  • The prescribing healthcare provider must submit clinical documentation supporting the medical necessity of Semaglutide (Wegovy).

 

Continuation of Therapy Criteria

 

  • Demonstrate significant weight loss or clinical improvement in weight-related comorbid conditions after initial treatment period, typically 3 to 6 months.
  •  

  • Provide ongoing documentation of weight management and adherence to therapy.

 

Additional Information

 

  • Coverage may require the patient to be enrolled in a comprehensive weight management program that includes lifestyle changes such as diet and exercise counseling.
  •  

  • Review and approval of coverage are subject to change based on the latest clinical guidelines and policy adjustments by Blue Shield of California.

 

Why Blue Shield of California Might Deny Semaglutide (Wegovy) Coverage

 

Situations Where Blue Shield of California Might Deny Semaglutide (Wegovy) Coverage

 

  • If the patient does not meet the pre-specified medical criteria or guidelines for obesity treatment set by Blue Shield of California.
  •  

  • When the prescribed semaglutide is not related to a diagnosed medical condition covered under the plan. Usage for non-approved conditions may lead to denial.
  •  

  • For patients who have not tried and failed first-line treatments or alternative medications for weight management, as per Blue Shield of California's step therapy policy.
  •  

  • If semaglutide is prescribed for off-label uses that are not recognized or authorized by Blue Shield of California's policy guidelines.
  •  

  • In cases where there is insufficient clinical documentation supporting the necessity and effectiveness of semaglutide for the patient's specific health condition.
  •  

  • When the medication is obtained from a provider or pharmacy that is not within the Blue Shield network or if it is not part of the formulary list.
  •  

  • If the patient exceeds the coverage limits specified for the medication or upon reaching lifetime limits specified in the policy terms and conditions.
  •  

  • For doses exceeding the maximum limits approved by the FDA or as defined in Blue Shield's policy for semaglutide administration.
  •  

  • When semaglutide is prescribed for individuals below the authorized age limit specified by the policy.
  •  

  • If prior authorization requirements are not completed or fulfilled, leading to a denial based on policy non-compliance.

 

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How Much Does Semaglutide (Wegovy) Cost without Insurance?

 

Approximate Cost of Semaglutide (Wegovy) Without Insurance

 

  • The price of Semaglutide, commonly known as Wegovy, without insurance can be substantial, typically ranging between $1,200 and $1,400 for a supply that lasts approximately one month.
  •  

  • This medication is designed for long-term weight management, thus planning financially for sustained use is important if paying out of pocket.
  •  

  • It's important to note that prices can vary based on the pharmacy, geographic location, and available discounts or pharmacy loyalty programs.
  •  

  • Patients are encouraged to seek patient assistance programs or discounts to help mitigate costs. Some pharmaceutical manufacturers offer discount cards or assistance programs to help with the cost of prescription medications like Wegovy.

 

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 Semaglutide (Wegovy) Coverage with Blue Shield of California

 

Verify Your Coverage Plan

 

  • Log into your Blue Shield of California online account to review your specific health plan details.
  •  

  • Check your Summary of Benefits and Coverage document to see if prescription medications like Wegovy are covered under your current plan.
  •  

  • Contact Blue Shield’s customer service directly to inquire if Semaglutide (Wegovy) is included in your plan and confirm any specifics regarding it.

 

Consult with Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss your eligibility for Semaglutide (Wegovy).
  •  

  • Ensure your doctor is aware that this medication needs to be covered by insurance and is ready to provide any necessary documentation.
  •  

  • Ask your healthcare provider to write a prescription for Wegovy if they deem it appropriate for your health needs.

 

Pre-authorization Request

 

  • Work with your healthcare provider’s office to submit a pre-authorization request to Blue Shield of California. This process may involve providing medical records or other documentation justifying the need for Wegovy.
  •  

  • Ensure all necessary forms and documentation are completed accurately to avoid delays in processing.

 

Follow Up with Insurance

 

  • Contact Blue Shield to confirm receipt of the pre-authorization request and inquire about the expected timeline for a decision.
  •  

  • Check your Blue Shield account or contact customer service for updates on your pre-authorization status.
  •  

  • Be prepared to provide additional documentation or clarification if Blue Shield requests more information.

 

Appeal If Necessary

 

  • If your initial request is denied, review the denial letter carefully to understand the reasons behind the decision.
  •  

  • Work with your healthcare provider to gather any additional information that might strengthen your case for coverage.
  •  

  • Submit an appeal to Blue Shield following their specified procedures, providing all necessary documentation to support your request.

 

Continual Monitoring and Communication

 

  • After approval, ensure that your pharmacy receives the prescription authorization from Blue Shield and that Wegovy is available for you to obtain.
  •  

  • Stay in contact with both your healthcare provider and Blue Shield to ensure any future renewals or additional authorizations are handled promptly.
  •  

  • Keep records of all communications with Blue Shield and your healthcare provider related to your Wegovy coverage.

 

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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.

Semaglutide (Wegovy) FAQ

1. What are the common side effects of Semaglutide (Wegovy)?

 

Common Side Effects of Semaglutide (Wegovy)

 

  • Nausea  — Often occurs at the start of treatment and may decrease over time.
  •  

  • Vomiting  — Related to gastrointestinal upset; usually temporary.
  •  

  • Diarrhea  — Common and may vary in intensity.
  •  

  • Constipation  — It can occur alongside other digestive issues.
  •  

  • Abdominal Pain  — Includes discomfort or cramping sensation.
  •  

  • Headache  — Typically mild but can be persistent.
  •  

  • Dizziness  — May affect balance or result in vertigo-like symptoms.
  •  

  • Fatigue  — Some patients report general tiredness or lack of energy.

 

2. How much weight can I lose with Semaglutide (Wegovy)?

 

Potential Weight Loss with Semaglutide (Wegovy)

 

  • Clinical trials demonstrate that Semaglutide (Wegovy) helps individuals lose a significant amount of weight. On average, participants experienced a weight loss of about 15% of their initial body weight over 68 weeks.
  •  

  • Results vary, with some losing more and others less. Factors include adherence to medication, lifestyle changes, and individual metabolic responses.
  •  

  • Semaglutide should be part of a comprehensive weight management program, including a reduced-calorie diet and increased physical activity.
  •  

  • Consult with a healthcare professional for personalized advice and to discuss possible side effects like nausea or gastrointestinal issues.

 

3. Is Wegovy the same as Ozempic?

 

Differences Between Wegovy and Ozempic

 

  • Formulation: Both contain semaglutide, a GLP-1 receptor agonist, but are formulated for different purposes.
  •  

  • Indication: Wegovy is primarily for weight management in adults with obesity. Ozempic is prescribed for type 2 diabetes management.
  •  

  • Dosage: While both are weekly injections, Wegovy generally has higher dosing than Ozempic (up to 2.4mg vs. 1mg for Ozempic).
  •  

  • Side Effects: Common side effects overlap, including nausea, but may vary in intensity due to different dosages.

 

Conclusion

 

  • Though similar, they serve distinct medical purposes. Always consult your healthcare provider for personalized advice.

 

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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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