Does Fallon Community Health Plan (FCHP) Cover Liraglutide (Saxenda)

Explore FCHP's coverage on Liraglutide (Saxenda), reasons for denial, how to secure coverage, cost without insurance, and FAQ.
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Coverage for Liraglutide (Saxenda) by FCHP

 

  • Fallon Community Health Plan (FCHP) may cover Liraglutide (Saxenda) under specific conditions related to obesity management. Coverage depends on the plan and individual circumstances, as guidelines can vary.
  •  

  • Generally, patients must meet criteria such as a BMI of 30 or higher, or 27 with obesity-related health conditions, to qualify for coverage. Medical necessity documentation might be required to support the prescription.
  •  

  • Prior authorization is often necessary. The prescribing physician should provide relevant medical history and justify the need for Saxenda.
  •  

  • Coverage may also depend on step therapy protocols, where patients need to try other medications or lifestyle interventions first.
  •  

  • Patients should verify specific plan details with FCHP, as formularies and policies can change.

 

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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.

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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 Liraglutide (Saxenda) Coverage with Fallon Community Health Plan (FCHP)

 

Verify Your Eligibility

 

  • Contact Fallon Community Health Plan (FCHP) customer service to understand if your specific plan provides coverage for Liraglutide (Saxenda).
  •  

  • Check the FCHP formulary on their website to see if Liraglutide is listed as a covered medication.
  •  

  • Determine if there are any specific criteria or pre-existing conditions required for coverage.

 

Consult with Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss your need for Liraglutide (Saxenda) for weight management or diabetes treatment.
  •  

  • Ensure your healthcare provider is prepared to supply any necessary documentation, such as medical records or a letter of medical necessity.

 

Obtain Prescription

 

  • If your healthcare provider deems Liraglutide necessary, obtain a prescription for the medication.
  •  

  • Ensure that the prescription includes any required information, such as dosage and diagnosis codes.

 

Connect with FCHP Pharmacy Services

 

  • Contact FCHP's Pharmacy Services to inquire about the procedure for prior authorization, if necessary.
  •  

  • Submit your prescription details and any supporting documents required for prior authorization.

 

Complete Prior Authorization

 

  • Work with your healthcare provider and FCHP to complete any prior authorization forms, highlighting the medical necessity for Liraglutide.
  •  

  • Provide any additional information requested by FCHP to facilitate the authorization process.

 

Follow Up and Confirm Coverage

 

  • Stay in contact with FCHP and your healthcare provider to monitor the status of your prior authorization.
  •  

  • Once approved, confirm the coverage details, including copayments or coinsurance responsibilities.

 

Utilize Pharmacies in Network

 

  • Ensure that you fill your prescription at a pharmacy that is within FCHP's network to maximize your benefits.
  •  

  • Verify that the pharmacy is aware of your coverage details for proper billing to FCHP.

 

Review and Appeal if Necessary

 

  • If coverage is denied, review the denial letter from FCHP to understand their reasoning.
  •  

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

  • Submit an appeal to FCHP with the required documentation and follow up regularly on the status.

 

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FAQs

Does Fallon Community Health Plan (FCHP) Cover Liraglutide (Saxenda)

Explore FCHP's coverage on Liraglutide (Saxenda), reasons for denial, how to secure coverage, cost without insurance, and FAQ.
Curex allergy drops unboxing

Is Liraglutide (Saxenda) Covered by Fallon Community Health Plan (FCHP)

 

Coverage for Liraglutide (Saxenda) by FCHP

 

  • Fallon Community Health Plan (FCHP) may cover Liraglutide (Saxenda) under specific conditions related to obesity management. Coverage depends on the plan and individual circumstances, as guidelines can vary.
  •  

  • Generally, patients must meet criteria such as a BMI of 30 or higher, or 27 with obesity-related health conditions, to qualify for coverage. Medical necessity documentation might be required to support the prescription.
  •  

  • Prior authorization is often necessary. The prescribing physician should provide relevant medical history and justify the need for Saxenda.
  •  

  • Coverage may also depend on step therapy protocols, where patients need to try other medications or lifestyle interventions first.
  •  

  • Patients should verify specific plan details with FCHP, as formularies and policies can change.

 

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Fallon Community Health Plan (FCHP)'s Approved Criteria for Liraglutide (Saxenda) Coverage

 

Fallon Community Health Plan (FCHP) Approved Criteria for Liraglutide (Saxenda) Coverage

 

  • **Eligibility Criteria**: Must be 18 years or older with a body mass index (BMI) greater than or equal to 30 kg/m² or greater than or equal to 27 kg/m² with at least one weight-related comorbidity such as hypertension, type 2 diabetes, or dyslipidemia.
  •  

  • **Previous Weight Loss Attempts**: Documentation of unsuccessful attempts to lose weight through a structured diet and exercise program. Required proof of participation in a comprehensive weight management program within the past year.
  •  

  • **Medical Evaluation**: A thorough evaluation by the prescribing healthcare provider confirming that the patient does not have any contraindications to Liraglutide (Saxenda) use, such as a personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2.
  •  

  • **Prescriber Qualifications**: Prescription needs to be written by or in consultation with a specialist in endocrinology, diabetology, or a healthcare professional specializing in weight management.
  •  

  • **Treatment Plan**: Requirement for an individualized comprehensive plan aimed at long-term weight management, including a reduced-calorie diet and increased physical activity as part of the treatment with Liraglutide (Saxenda).
  •  

  • **Reassessment**: Continuation beyond an initial prescription period depends on clinically significant weight loss (e.g., a 4% reduction from baseline) occurring within the first 16 weeks of therapy.
  •  

  • **Monitoring**: Continuous monitoring and follow-up consultations are necessary to assess the effectiveness and safety of the therapy. Documentation of all follow-ups should be available for review.

 

Why Fallon Community Health Plan (FCHP) Might Deny Liraglutide (Saxenda) Coverage

 

Situations Where Fallon Community Health Plan (FCHP) Does Not Cover Liraglutide (Saxenda)

 

  • Liraglutide (Saxenda) may not be covered if the prescription is intended for a diagnosis other than chronic weight management or obesity treatment. It should be noted that Saxenda is primarily approved for weight management.
  •  

  • The health plan might deny coverage if the patient's body mass index (BMI) does not meet the required threshold to qualify for Saxenda treatment. Typically, BMI requirements must align with federal and plan-specific guidelines, which FCHP adheres to strictly.
  •  

  • FCHP may deny coverage in cases where there is insufficient documentation of previously attempted weight loss methods. Documentation that fails to demonstrate the ineffectiveness of prior methods like lifestyle intervention, diet, or exercise could lead to a denial.
  •  

  • If Liraglutide (Saxenda) is prescribed without adherence to required pre-authorization procedures, insurance coverage by FCHP may be denied. Pre-authorization ensures that the coverage criteria are met, and skipping this step could result in non-coverage.
  •  

  • FCHP might not cover Saxenda if the prescribed dosage or administration does not follow FDA-approved guidelines. Any deviation from recommended usage based on the prescribing information can lead to coverage denial.
  •  

  • In scenarios where Saxenda is used concurrently with other GLP-1 receptor agonists or similar medications, FCHP may deny coverage. Such double therapy typically falls outside of coverage rules due to safety and efficacy concerns.
  •  

  • The health plan might also deny coverage if there is evidence of non-compliance with treatment protocols in the patient's medical history. Adherence to the prescribed weight management plan is crucial for continued 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 Fallon Community Health Plan (FCHP)

 

Verify Your Eligibility

 

  • Contact Fallon Community Health Plan (FCHP) customer service to understand if your specific plan provides coverage for Liraglutide (Saxenda).
  •  

  • Check the FCHP formulary on their website to see if Liraglutide is listed as a covered medication.
  •  

  • Determine if there are any specific criteria or pre-existing conditions required for coverage.

 

Consult with Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss your need for Liraglutide (Saxenda) for weight management or diabetes treatment.
  •  

  • Ensure your healthcare provider is prepared to supply any necessary documentation, such as medical records or a letter of medical necessity.

 

Obtain Prescription

 

  • If your healthcare provider deems Liraglutide necessary, obtain a prescription for the medication.
  •  

  • Ensure that the prescription includes any required information, such as dosage and diagnosis codes.

 

Connect with FCHP Pharmacy Services

 

  • Contact FCHP's Pharmacy Services to inquire about the procedure for prior authorization, if necessary.
  •  

  • Submit your prescription details and any supporting documents required for prior authorization.

 

Complete Prior Authorization

 

  • Work with your healthcare provider and FCHP to complete any prior authorization forms, highlighting the medical necessity for Liraglutide.
  •  

  • Provide any additional information requested by FCHP to facilitate the authorization process.

 

Follow Up and Confirm Coverage

 

  • Stay in contact with FCHP and your healthcare provider to monitor the status of your prior authorization.
  •  

  • Once approved, confirm the coverage details, including copayments or coinsurance responsibilities.

 

Utilize Pharmacies in Network

 

  • Ensure that you fill your prescription at a pharmacy that is within FCHP's network to maximize your benefits.
  •  

  • Verify that the pharmacy is aware of your coverage details for proper billing to FCHP.

 

Review and Appeal if Necessary

 

  • If coverage is denied, review the denial letter from FCHP to understand their reasoning.
  •  

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

  • Submit an appeal to FCHP with the required documentation and follow up regularly on the status.

 

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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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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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