Does Blue Shield of California Cover Tirzepatide (Mounjaro)

Explore Tirzepatide coverage with Blue Shield of California, reasons for denial, cost without insurance, and FAQs to help navigate your coverage options.
Curex allergy drops unboxing
“Curex is changing the landscape of allergies in 2024”
man opening Curex packaging
man opening Curex packaging

 

Coverage of Tirzepatide (Mounjaro) by Blue Shield of California

 

  • Tirzepatide may be covered under Blue Shield of California's health plans if it's deemed medically necessary for managing Type 2 Diabetes.
  •  

  • Coverage typically requires prior authorization, where the prescribing physician must provide documented evidence of medical necessity and previous treatments tried.
  •  

  • Patients with specific clinical criteria, such as insufficient glycemic control with other medications, may qualify for coverage.
  •  

  • The plan may impose quantity limits and step therapy, requiring the use of other preferred medications before approving Tirzepatide.
  •  

  • Patients should consult with their health plan or provider to ensure eligibility and understand specific coverage terms and criteria.

 

Want to try immunotherapy?

Start with Curex

Covered

Uncovered

Treat your allergies with Curex - $49  $9.99

Review your allergy test results with a Curex allergist.

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 Tirzepatide (Mounjaro) Coverage with Blue Shield of California

 

Verify Your Coverage

 

  • Log in to your Blue Shield of California member portal to review your current policy details. Look for any mention of prescription drug coverage or formularies that include Tirzepatide (Mounjaro).
  •  

  • Contact customer service directly via the phone number on your insurance card to ask if your plan covers Tirzepatide and under what conditions.

 

Consult With Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss your need for Tirzepatide (Mounjaro). Ensure that they understand your medical necessity for this medication.
  •  

  • Request that your healthcare provider provide documentation that supports the need for Tirzepatide, such as medical records and a recommendation letter.

 

Request Prior Authorization

 

  • Ask your healthcare provider to initiate a prior authorization request through Blue Shield of California. This process is crucial to confirm medical necessity and to seek coverage approval.
  •  

  • Follow up with your provider to ensure all required documentation is submitted to your insurance company promptly to avoid delays.

 

Check the Formularies

 

  • Access the formulary list on the Blue Shield of California website to see if Tirzepatide (Mounjaro) is listed and what tier it is categorized under, as this can affect your out-of-pocket cost.
  •  

  • If Tirzepatide is not included, contact Blue Shield to ask about steps for an exception process or consideration for off-formulary coverage.

 

Appeal Denied Coverage

 

  • If your initial request is denied, seek a clear explanation for the denial from Blue Shield of California's customer service.
  •  

  • Work with your healthcare provider to gather any additional supporting documents needed for an appeal.
  •  

  • Submit the appeal with all supplemental documentation to Blue Shield promptly and keep a record of all communications and submissions.

 

Consider Alternative Options

 

  • If coverage is still not granted, discuss alternative medications or treatment options with your healthcare provider that might be covered under your current plan.
  •  

  • Investigate manufacturer savings programs or patient assistance programs that might provide financial support or discounts for Tirzepatide.

 

Curex allergy drops unboxing

We love helping people!

Allie, Nevada

five stars

"I have two cats I can finally cuddle!"

Cat and dog allergies

Zachary, Texas

five stars

“I can breathe through my nose for the first time in like 20 years!"

dust allergy
mold allergy

Dust and mold allergies

Erika, New York

five stars

“I've noticed less sneezing and shortness of breath.”

tree allergy
grass allergy

Tree and grass allergies

Richard, Texas

five stars


I love the convenience!

tree allergy

Tree and cat allergies

We Treat Food, Indoor & Outdoor Allergies

tree allergy
Tree Pollens
maple leaf icon
Weed Pollens
Cat Allergies
Dog Allergies
insect icon
Dust Mites
mold allergy
Molds
Food Allergies
 curex user showing allergy treatment kita patient showing allergy treatment boxa male patient showing allergy drops vial
50,000+ users have overcome their allergies
Am I eligible?

Benefits of Curex

At-home treatment

Apply treatments in minutes from the comfort of your own home with under-the-tongue applications instead of shots or pills

5-30x higher cumulative dose vs allergy shots

Sublingual immunotherapy delivers a higher dose of allergens over the course of treatment.

Potential for results in as few as 6 months

Individual results vary but some users have reported a noticeable difference in as few as 6-12 months since starting treatments

Excellent safety profile

Studies that have been reviewed by certified physicians show that sublingual immunotherapy is a safe treatment option
male medical practitioner smiling

Treatment prescribed
by clinician

1
right line icon
Curex packaging

Clinicaly made allergen extracts are customized for your allergies

2
right line icon
insect icon
grass icon
man opening Curex packaging

Your immune system gets desensitized to allergens, giving you long-term relief.

3

FAQs

Does Blue Shield of California Cover Tirzepatide (Mounjaro)

Explore Tirzepatide coverage with Blue Shield of California, reasons for denial, cost without insurance, and FAQs to help navigate your coverage options.
Curex allergy drops unboxing

Is Tirzepatide (Mounjaro) Covered by Blue Shield of California

 

Coverage of Tirzepatide (Mounjaro) by Blue Shield of California

 

  • Tirzepatide may be covered under Blue Shield of California's health plans if it's deemed medically necessary for managing Type 2 Diabetes.
  •  

  • Coverage typically requires prior authorization, where the prescribing physician must provide documented evidence of medical necessity and previous treatments tried.
  •  

  • Patients with specific clinical criteria, such as insufficient glycemic control with other medications, may qualify for coverage.
  •  

  • The plan may impose quantity limits and step therapy, requiring the use of other preferred medications before approving Tirzepatide.
  •  

  • Patients should consult with their health plan or provider to ensure eligibility and understand specific coverage terms and criteria.

 

A weight management program tailored to you

Start with Curex

Blue Shield of California's Approved Criteria for Tirzepatide (Mounjaro) Coverage

 

Criteria for Tirzepatide (Mounjaro) Coverage

 

  • The patient must have a confirmed diagnosis of type 2 diabetes mellitus and require assistance in improving glycemic control.
  •  

  • The patient should be 18 years of age or older.
  •  

  • The prescriber must document that the patient has tried at least one other diabetes medication such as metformin, a sulfonylurea, or insulin, and has had inadequate glycemic control.
  •  

  • The patient needs to be actively engaged in an appropriate diet and exercise program aimed at weight management and glycemic control.
  •  

  • There must be documented medical necessity for Tirzepatide (Mounjaro) use due to inadequate control with existing antidiabetic agents.

 

Medical Expertise and Monitoring Requirement

 

  • The prescriber must be an endocrinologist or a healthcare provider with appropriate expertise in managing diabetes.
  •  

  • Regular monitoring of glycemic control and adjustment of dosage must be documented in the medical records.
  •  

  • The healthcare provider must assess for potential side effects and document management strategies tailored to the patient's needs.

 

Duration and Renewal Criteria

 

  • Initial coverage approval is typically for a three-month period to assess efficacy and tolerability.
  •  

  • Renewal of coverage requires documentation of improved glycemic control, adherence to the treatment regimen, and an evaluation of side effects.
  •  

  • Continued coverage necessitates a formal review every six months to ensure ongoing medical necessity and positive treatment outcomes.

 

Additional Qualification Parameters

 

  • Body Mass Index (BMI) criteria may be considered as additional factors for coverage approval.
  •  

  • The presence of comorbid conditions that justify the addition of Tirzepatide (Mounjaro) to the treatment regimen could qualify a patient for coverage.

 

Why Blue Shield of California Might Deny Tirzepatide (Mounjaro) Coverage

 

Reasons for Coverage Denial of Tirzepatide (Mounjaro) by Blue Shield of California

 

  • The medication is not FDA-approved for the specific condition for which it is being prescribed.
  •  

  • The patient does not meet the clinical criteria and guidelines set forth by Blue Shield of California, such as specific medical history or diagnostic results.
  •  

  • Tirzepatide is classified as experimental or investigational for the patient’s condition as per clinical guidelines by Blue Shield of California.
  •  

  • The prescription does not comply with the formularies or preferred drug lists utilized by Blue Shield of California.
  •  

  • There is insufficient documentation or evidence of failed prior therapy, which is typically required before approval for coverage.
  •  

  • Usage is for off-label purposes without sufficient clinical evidence to justify its efficacy or safety for the intended treatment.
  •  

  • The request exceeds established quantity limits without a compelling justification accompanied by the necessary supporting information.
  •  

  • The patient has not exhausted other covered treatment options, following the step therapy protocols established by Blue Shield of California.
  •  

 

Together with our partners we have changed the lives of over 300,000 patients.

How Much Does Tirzepatide (Mounjaro) Cost without Insurance?

 

Cost of Tirzepatide (Mounjaro) Without Insurance

 

  • The approximate cost of Tirzepatide, commonly known by its brand name Mounjaro, can vary based on several factors including the pharmacy location and any available discounts.
  •  

  • On average, the price for four doses of Mounjaro, which is typically a one-month supply, is estimated to be between $1,000 and $1,250 without any insurance coverage.
  •  

  • It's essential for patients to check with different pharmacies and consider available savings programs or manufacturer coupons which might offer significant reductions or discounts.
  •  

  • Additionally, some pharmacies might provide membership programs or discount cards that could further lower the costs.

 

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 Tirzepatide (Mounjaro) Coverage with Blue Shield of California

 

Verify Your Coverage

 

  • Log in to your Blue Shield of California member portal to review your current policy details. Look for any mention of prescription drug coverage or formularies that include Tirzepatide (Mounjaro).
  •  

  • Contact customer service directly via the phone number on your insurance card to ask if your plan covers Tirzepatide and under what conditions.

 

Consult With Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss your need for Tirzepatide (Mounjaro). Ensure that they understand your medical necessity for this medication.
  •  

  • Request that your healthcare provider provide documentation that supports the need for Tirzepatide, such as medical records and a recommendation letter.

 

Request Prior Authorization

 

  • Ask your healthcare provider to initiate a prior authorization request through Blue Shield of California. This process is crucial to confirm medical necessity and to seek coverage approval.
  •  

  • Follow up with your provider to ensure all required documentation is submitted to your insurance company promptly to avoid delays.

 

Check the Formularies

 

  • Access the formulary list on the Blue Shield of California website to see if Tirzepatide (Mounjaro) is listed and what tier it is categorized under, as this can affect your out-of-pocket cost.
  •  

  • If Tirzepatide is not included, contact Blue Shield to ask about steps for an exception process or consideration for off-formulary coverage.

 

Appeal Denied Coverage

 

  • If your initial request is denied, seek a clear explanation for the denial from Blue Shield of California's customer service.
  •  

  • Work with your healthcare provider to gather any additional supporting documents needed for an appeal.
  •  

  • Submit the appeal with all supplemental documentation to Blue Shield promptly and keep a record of all communications and submissions.

 

Consider Alternative Options

 

  • If coverage is still not granted, discuss alternative medications or treatment options with your healthcare provider that might be covered under your current plan.
  •  

  • Investigate manufacturer savings programs or patient assistance programs that might provide financial support or discounts for Tirzepatide.

 

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.

Tirzepatide (Mounjaro) FAQ

What are common side effects of Tirzepatide (Mounjaro)?

 

Common Side Effects of Tirzepatide (Mounjaro)

 

  • Nausea: Frequently reported, especially when starting treatment or increasing the dose.
  •  

  • Diarrhea: Some patients experience loose stools during treatment.
  •  

  • Decreased Appetite: Commonly occurs and can aid in weight management.
  •  

  • Vomiting: May happen occasionally, often alongside nausea.
  •  

  • Constipation: Some individuals might experience slower bowel movements.
  •  

  • Abdominal Pain: Discomfort or pain may occur during therapy.
  •  

  • Fatigue: A feeling of tiredness or exhaustion might present itself in some users.
  •  

  • In rare cases, hypoglycemia occurs, especially if combined with insulin or sulfonylureas.

 

How does Tirzepatide (Mounjaro) help with weight loss?

 

How Tirzepatide Aids Weight Loss

 

  • Dual Agonist Action: Tirzepatide acts on both GLP-1 and GIP receptors. These hormones help regulate appetite and glucose, influencing energy balance and metabolism.
  •  

  • Appetite Suppression: By mimicking these hormones, it reduces hunger, promoting lower calorie intake.
  •  

  • Increased Satiety: Delays gastric emptying, enhancing fullness and reducing meal frequency.
  •  

  • Improved Blood Sugar Control: Helps stabilize blood glucose levels, reducing insulin spikes that can stimulate hunger.
  •  

  • Enhanced Energy Expenditure: Modulates metabolic pathways to increase calorie burning, aiding fat loss.

 

Is Tirzepatide (Mounjaro) the same as Ozempic or Wegovy?

 

Comparing Tirzepatide with Ozempic and Wegovy

 

  • Composition: Tirzepatide (Mounjaro), Ozempic, and Wegovy are different medications. Tirzepatide is a dual GIP and GLP-1 receptor agonist, whereas Ozempic and Wegovy contain semaglutide, a GLP-1 receptor agonist.
  •  

  • Indications: Both Ozempic and Mounjaro target type 2 diabetes, but Wegovy is approved mainly for chronic weight management.
  •  

  • Mechanism: All induce insulin secretion and appetite suppression, yet Mounjaro's dual action may offer distinct benefits in glucose control and weight loss.
  •  

  • Dosage and Administration: Dosage forms and protocols vary; always follow medical guidance specific to the prescribed drug.
  •  

  • Considerations: Always consult your healthcare provider to determine the best option based on personal health needs and conditions.

 

Have questions left?

Get a personalized online consultation with a doctor at Curex

Curex is one of America’s largest telehealth providers

Together with our partners we have changed the lives of over 300,000 patients. Here’s what some of them have to say:

“Curex has performed beyond my expectations. I am feeling tremendously better and look forward to continuing the treatment.”
Becky D.
"If I could give 6 stars, I would. BEST... BEST… BEST… service.”
Ferdian K.
“The Curex staff has been professional, efficient, and really focused on my individual needs.”
Ana C.

Start your
journey now

Everything you need is included:

Online consultation

Your prescription

Premium medication

Overnight shipping

Ongoing support

A weight management program tailored to you

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.

Made in Webflow