Does EmblemHealth Cover Semaglutide (Wegovy)

Explore EmblemHealth's coverage of Semaglutide (Wegovy), costs without insurance, and tips to secure approval. Get answers to FAQs about this medication.
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Coverage for Semaglutide (Wegovy)

 

  • EmblemHealth may provide coverage for Semaglutide (Wegovy) if prescribed for chronic weight management in adults with a BMI of 30 or more, or 27 or more with weight-related health issues.

 

Criteria for Coverage

 

  • The patient must have evidence of a commitment to a weight management program that includes a reduced-calorie diet and increased physical activity.
  • Documentation of prior weight loss attempts and metabolic tests may be required to demonstrate medical necessity.

 

Basic Rules for Approval

 

  • Pre-approval or prior authorization is generally needed to confirm coverage for Semaglutide (Wegovy).
  • Review the plan specifics, as coverage policies can vary based on the EmblemHealth plan type and state regulations.

 

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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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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 EmblemHealth

 

Verify Your EmblemHealth Plan Details

 

  • Review your current EmblemHealth plan documents to confirm if prescription drug coverage is included.
  •  

  • Check for any specific mentions of weight management medications or exclusions related to Semaglutide (Wegovy).

 

Consult with Your Healthcare Provider

 

  • Discuss your interest in Semaglutide (Wegovy) with your physician to evaluate if it's suitable for your weight management goals.
  •  

  • Obtain a prescription or a documented recommendation from your healthcare provider if Semaglutide (Wegovy) is deemed appropriate.

 

Contact EmblemHealth for Coverage Information

 

  • Reach out to EmblemHealth customer service via phone or their website to inquire about Semaglutide (Wegovy) coverage details.
  •  

  • Ask about any specific requirements or documents needed for medication approval, such as prior authorization forms or a physician's statement.

 

Submit a Prior Authorization Request

 

  • Work with your healthcare provider to complete any required prior authorization forms that EmblemHealth mandates for Semaglutide (Wegovy).
  •  

  • Ensure that all forms are filled out correctly and submit them to EmblemHealth for processing.

 

Follow Up on Authorization Status

 

  • After submission, keep track of your authorization status by contacting EmblemHealth periodically.
  •  

  • Request updates on any additional information or actions needed to process your request efficiently.

 

Appeal if Coverage is Denied

 

  • If your initial request for coverage is denied, review EmblemHealth's rationale and gather any necessary supporting documents from your healthcare provider.
  •  

  • File an appeal according to EmblemHealth’s specified procedures, ensuring you meet all deadlines and requirements.

 

Consider Additional Financial Assistance

 

  • If needed, research patient assistance programs provided by the manufacturer of Semaglutide (Wegovy) to reduce out-of-pocket costs.
  •  

  • Explore other resources such as discounts, rebates, or copay cards that might be available.

 

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FAQs

Does EmblemHealth Cover Semaglutide (Wegovy)

Explore EmblemHealth's coverage of Semaglutide (Wegovy), costs without insurance, and tips to secure approval. Get answers to FAQs about this medication.
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Is Semaglutide (Wegovy) Covered by EmblemHealth

 

Coverage for Semaglutide (Wegovy)

 

  • EmblemHealth may provide coverage for Semaglutide (Wegovy) if prescribed for chronic weight management in adults with a BMI of 30 or more, or 27 or more with weight-related health issues.

 

Criteria for Coverage

 

  • The patient must have evidence of a commitment to a weight management program that includes a reduced-calorie diet and increased physical activity.
  • Documentation of prior weight loss attempts and metabolic tests may be required to demonstrate medical necessity.

 

Basic Rules for Approval

 

  • Pre-approval or prior authorization is generally needed to confirm coverage for Semaglutide (Wegovy).
  • Review the plan specifics, as coverage policies can vary based on the EmblemHealth plan type and state regulations.

 

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EmblemHealth's Approved Criteria for Semaglutide (Wegovy) Coverage

 

Criteria for Initial Coverage of Semaglutide (Wegovy)

 

  • The patient must have a documented diagnosis of obesity, defined as a Body Mass Index (BMI) of 30 kg/m² or greater.
  •  

  • Alternatively, the patient may qualify if they have a BMI of 27 kg/m² or greater and at least one weight-related comorbidity, such as Type 2 diabetes, hypertension, or dyslipidemia.
  •  

  • There must be documented evidence that the patient has previously attempted to lose weight through lifestyle modifications without adequate success. This includes diet, exercise, and behavioral changes.
  •  

  • The prescribing physician should provide a comprehensive assessment indicating the necessity of pharmacological intervention as part of an overall weight management plan.

 

Ongoing Coverage Criteria for Semaglutide (Wegovy)

 

  • The patient must demonstrate an adequate response to the medication, defined as a reduction in body weight of at least 5% from baseline after 12 weeks on the maintenance dose of Semaglutide.
  •  

  • Continued use of Semaglutide must be part of a managed care plan that includes ongoing lifestyle modifications. This plan should be overseen by a healthcare provider.
  •  

  • The prescribing healthcare provider must conduct regular follow-ups to monitor the patient's progress, side effects, and overall health condition.
  •  

  • Documentation of continued improvement or maintenance of weight loss is required to justify continuance of coverage.

 

Conditions for Reauthorization

 

  • Reauthorization will require evidence that the patient continues to benefit from the use of Semaglutide, consistent with the criteria outlined for ongoing coverage.
  •  

  • Updated documentation demonstrating adherence to the prescribed weight management plan, including lifestyle modifications, will be necessary.
  •  

  • The patient's health records should reflect regular assessments of risk factors associated with obesity-related conditions, as managed by healthcare professionals.

 

Why EmblemHealth Might Deny Semaglutide (Wegovy) Coverage

 

Reasons for Denial of Coverage for Semaglutide (Wegovy) by EmblemHealth

 

  • **Non-Compliance with Medical Necessity Criteria**: EmblemHealth may deny coverage if the patient's medical records do not demonstrate a medical necessity for Semaglutide (Wegovy) according to their specific guidelines.
  •  

  • **Inappropriate Diagnosis**: Coverage could be denied if the prescribed use of Semaglutide (Wegovy) does not align with the approved diagnoses under EmblemHealth's policy.
  •  

  • **Lack of Prior Authorization**: If prior authorization requirements have not been met, EmblemHealth may refuse coverage for the medication. This could include not securing approval before the drug is dispensed.
  •  

  • **Failure to Meet Age Restrictions**: Coverage might be denied if the patient prescribed Semaglutide (Wegovy) is outside the age specifications outlined by EmblemHealth.
  •  

  • **Absence of Required Documentation**: If all necessary supporting documents are not submitted, such as detailed medical history or evidence of previous treatments, this could lead to a denial.
  •  

  • **Excluded Plan Benefits**: Coverage may be denied if the plan specifically excludes weight management drugs from its benefits.
  •  

  • **Exceeding Dosage and Frequency Limits**: Use of the medication beyond the dosage or frequency limitations set by EmblemHealth guidelines could result in denial.
  •  

  • **Non-Formulary Drug**: If Semaglutide (Wegovy) is not listed on the plan’s formulary or preferred drug list, it might not be covered, especially if exclusions apply.

 

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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 EmblemHealth

 

Verify Your EmblemHealth Plan Details

 

  • Review your current EmblemHealth plan documents to confirm if prescription drug coverage is included.
  •  

  • Check for any specific mentions of weight management medications or exclusions related to Semaglutide (Wegovy).

 

Consult with Your Healthcare Provider

 

  • Discuss your interest in Semaglutide (Wegovy) with your physician to evaluate if it's suitable for your weight management goals.
  •  

  • Obtain a prescription or a documented recommendation from your healthcare provider if Semaglutide (Wegovy) is deemed appropriate.

 

Contact EmblemHealth for Coverage Information

 

  • Reach out to EmblemHealth customer service via phone or their website to inquire about Semaglutide (Wegovy) coverage details.
  •  

  • Ask about any specific requirements or documents needed for medication approval, such as prior authorization forms or a physician's statement.

 

Submit a Prior Authorization Request

 

  • Work with your healthcare provider to complete any required prior authorization forms that EmblemHealth mandates for Semaglutide (Wegovy).
  •  

  • Ensure that all forms are filled out correctly and submit them to EmblemHealth for processing.

 

Follow Up on Authorization Status

 

  • After submission, keep track of your authorization status by contacting EmblemHealth periodically.
  •  

  • Request updates on any additional information or actions needed to process your request efficiently.

 

Appeal if Coverage is Denied

 

  • If your initial request for coverage is denied, review EmblemHealth's rationale and gather any necessary supporting documents from your healthcare provider.
  •  

  • File an appeal according to EmblemHealth’s specified procedures, ensuring you meet all deadlines and requirements.

 

Consider Additional Financial Assistance

 

  • If needed, research patient assistance programs provided by the manufacturer of Semaglutide (Wegovy) to reduce out-of-pocket costs.
  •  

  • Explore other resources such as discounts, rebates, or copay cards that might be available.

 

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.

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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Everything you need is included:

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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.

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