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Does Fallon Community Health Plan (FCHP) Cover Lyrica

Explore Fallon Community Health Plan's coverage for Lyrica, reasons for denial, cost without insurance, and FAQs on securing coverage.
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Fallon Community Health Plan (FCHP) Coverage for Lyrica

 

  • FCHP typically covers Lyrica when prescribed for specific medical conditions such as fibromyalgia, diabetic nerve pain, spinal cord injury, or seizures.

    •  

  • For coverage, Lyrica should be deemed medically necessary by the prescribing physician, and the condition should be documented in the patient's medical records.

    •  

  • Prior authorization may be required. The healthcare provider usually submits the necessary forms and documentation to initiate the process.

    •  

  • FCHP may require evidence that alternative medications have not been effective before approving Lyrica.

    •  

  • Patients are encouraged to review their specific plan benefits and consult with their healthcare provider or FCHP directly to understand all requirements and criteria for coverage.

 

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Clinical Support

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 Lyrica Coverage with Fallon Community Health Plan (FCHP)

 

Check Your Prescription Benefits

 

  • Log into your Fallon Community Health Plan (FCHP) member portal to review your specific prescription drug benefits.

    •  

  • Look for the formulary list to confirm if Lyrica (pregabalin) is covered under your current plan.

    •  

  • If Lyrica is not listed, check for alternative medications that are covered and discuss them with your healthcare provider.

 

Discuss with Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss your need for Lyrica and any alternative treatments.

    •  

  • If Lyrica is the best option, your provider may need to submit a prior authorization request on your behalf to FCHP.

    •  

  • Gather any necessary medical documentation that supports the necessity of Lyrica for your condition.

 

Request Prior Authorization

 

  • Your healthcare provider should fill out and submit the prior authorization form provided by FCHP for Lyrica.

    •  

  • Ensure that all required information, such as diagnosis and previous treatment attempts, is included in the submission.

    •  

  • Follow up with your provider’s office to confirm that the prior authorization request has been submitted to FCHP.

 

Contact FCHP for Status Updates

 

  • Reach out to FCHP customer service to check the status of your prior authorization request.

    •  

  • Be prepared to provide your member ID and any reference number given by your healthcare provider.

    •  

  • Ask the representative for an estimated timeline for the review process and keep note of the expected response date.

 

Appeal If Necessary

 

  • If the prior authorization is denied, review the denial letter for specific reasons why it was not approved.

    •  

  • Work with your healthcare provider to strengthen your case by providing additional documentation or clarity on your medical need for Lyrica.

    •  

  • Submit an appeal to FCHP with the new information, and follow up periodically until a decision is reached.

 

Consider Additional Assistance Programs

 

  • If coverage is still denied, explore patient assistance programs offered by the manufacturer of Lyrica that might offer financial aid.

    •  

  • Discuss with your healthcare provider about any other therapeutic options that might be suitable and covered by FCHP.

 

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FAQs

Does Fallon Community Health Plan (FCHP) Cover Lyrica

Explore Fallon Community Health Plan's coverage for Lyrica, reasons for denial, cost without insurance, and FAQs on securing coverage.
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Is Lyrica Covered by Fallon Community Health Plan (FCHP)

 

Fallon Community Health Plan (FCHP) Coverage for Lyrica

 

  • FCHP typically covers Lyrica when prescribed for specific medical conditions such as fibromyalgia, diabetic nerve pain, spinal cord injury, or seizures.

    •  

  • For coverage, Lyrica should be deemed medically necessary by the prescribing physician, and the condition should be documented in the patient's medical records.

    •  

  • Prior authorization may be required. The healthcare provider usually submits the necessary forms and documentation to initiate the process.

    •  

  • FCHP may require evidence that alternative medications have not been effective before approving Lyrica.

    •  

  • Patients are encouraged to review their specific plan benefits and consult with their healthcare provider or FCHP directly to understand all requirements and criteria for coverage.

 

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

 

Criteria for Initial Authorization

 

  • Lyrica (pregabalin) is prescribed for a diagnosis that is FDA-approved. This may include conditions such as fibromyalgia, neuropathic pain associated with diabetic peripheral neuropathy or spinal cord injury, and postherpetic neuralgia.

    •  

  • The patient has tried and failed, or has contraindications to, first-line treatments specific to the condition being treated, such as gabapentin.

    •  

  • Documentation supporting the diagnosis and the medical necessity of Lyrica must be provided by the prescribing physician.

    •  

  • The patient meets any age requirements applicable to the specific condition for which Lyrica is being prescribed.

 

Criteria for Reauthorization

 

  • The patient has been adherent to the prescribed Lyrica regimen as confirmed by medical records.

    •  

  • There is clinical documentation showing an improvement in the patient's condition or symptoms as a result of Lyrica treatment.

    •  

  • The reauthorization request includes a continued need statement from the prescribing physician, certifying that Lyrica remains medically necessary for the patient.

    •  

  • There are no significant adverse reactions that could warrant discontinuation of Lyrica therapy.

 

Special Considerations

 

  • Lyrica coverage may also be considered for other off-label uses if there is robust clinical evidence supporting efficacy and safety.

    •  

  • If the prescribed use of Lyrica falls under non-standard or atypical guidelines, the prescribing physician must provide comprehensive documentation of the patient’s medical history and treatment rationale.

    •  

  • The patient should not be using alcohol or illicit drugs while taking Lyrica, as this could affect medication efficacy and safety.

 

Why Fallon Community Health Plan (FCHP) Might Deny Lyrica Coverage

 

Reasons for Lyrica Coverage Denial by Fallon Community Health Plan (FCHP)

 

  • Lyrica is prescribed for a condition that is not included in FCHP's approved indications. This could include off-label uses outside the accepted treatment guidelines.

    •  

  • The patient does not meet the specific medical necessity criteria established by FCHP, such as failing to demonstrate a documented history of specific medical conditions like neuropathic pain or fibromyalgia.

    •  

  • The patient has not tried and failed alternative therapies that are considered first-line treatments according to FCHP policy. If less expensive generics or better-established treatments are available and have not been utilized, coverage may be denied.

    •  

  • Maintenance or continued use of Lyrica is deemed unnecessary due to an absence of substantial improvement in symptoms or quality of life as assessed by the FCHP clinical guidelines.

    •  

  • Failure to adhere to or provide the necessary documentation or clinical assessments required by FCHP for coverage determination, such as recent medical evaluations or prior treatment records.

    •  

  • Prescription exceeds the dosage limits or frequency of use as prescribed by the FCHP guidelines, which might reflect standard safety and efficacy limits for Lyrica.

 

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How Much Does Lyrica Cost without Insurance?

 

Cost of Lyrica Without Insurance

 

  • The price of Lyrica without insurance can vary significantly depending on the pharmacy, geographic location, dosage, and quantity. On average, the cost can range between $460 to $720 for a 30-day supply when filling a common dosage such as 150 mg capsules.

    •  

  • Generic versions of Lyrica, known as pregabalin, are often significantly cheaper. The average cost for the generic version might be closer to $30 to $70 for a similar quantity and dosage.

    •  

  • Prices may also vary due to manufacturer's discounts, pharmacy membership programs, or coupon usage, which can help reduce the overall cost.

    •  

  • Comparing prices between local pharmacies or using online price comparison tools can help find the most affordable option.

 

Clinical Support

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 Lyrica Coverage with Fallon Community Health Plan (FCHP)

 

Check Your Prescription Benefits

 

  • Log into your Fallon Community Health Plan (FCHP) member portal to review your specific prescription drug benefits.

    •  

  • Look for the formulary list to confirm if Lyrica (pregabalin) is covered under your current plan.

    •  

  • If Lyrica is not listed, check for alternative medications that are covered and discuss them with your healthcare provider.

 

Discuss with Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss your need for Lyrica and any alternative treatments.

    •  

  • If Lyrica is the best option, your provider may need to submit a prior authorization request on your behalf to FCHP.

    •  

  • Gather any necessary medical documentation that supports the necessity of Lyrica for your condition.

 

Request Prior Authorization

 

  • Your healthcare provider should fill out and submit the prior authorization form provided by FCHP for Lyrica.

    •  

  • Ensure that all required information, such as diagnosis and previous treatment attempts, is included in the submission.

    •  

  • Follow up with your provider’s office to confirm that the prior authorization request has been submitted to FCHP.

 

Contact FCHP for Status Updates

 

  • Reach out to FCHP customer service to check the status of your prior authorization request.

    •  

  • Be prepared to provide your member ID and any reference number given by your healthcare provider.

    •  

  • Ask the representative for an estimated timeline for the review process and keep note of the expected response date.

 

Appeal If Necessary

 

  • If the prior authorization is denied, review the denial letter for specific reasons why it was not approved.

    •  

  • Work with your healthcare provider to strengthen your case by providing additional documentation or clarity on your medical need for Lyrica.

    •  

  • Submit an appeal to FCHP with the new information, and follow up periodically until a decision is reached.

 

Consider Additional Assistance Programs

 

  • If coverage is still denied, explore patient assistance programs offered by the manufacturer of Lyrica that might offer financial aid.

    •  

  • Discuss with your healthcare provider about any other therapeutic options that might be suitable and covered by FCHP.

 

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Lyrica FAQ

What are the common side effects of Lyrica?

 

Common Side Effects of Lyrica

 

  • Dizziness: Frequently reported, often occurring shortly after starting treatment.
  • Sleepiness: Commonly affects daily activities due to its sedative effects.
  • Weight Gain: Notable for some, monitoring weight is advised.
  • Swelling: Particularly in hands and feet; may require medical attention if severe.
  • Blurred Vision: Usually temporary but should be reported if persistent.
  • Dry Mouth: Sometimes improved with increased fluid intake.
  • Difficulty concentrating: Can affect mental clarity and focus.

 

Is Lyrica the same as gabapentin?

 

Differences Between Lyrica and Gabapentin

 

  • Classification: Both are anticonvulsants but with different active ingredients. Lyrica contains pregabalin, while gabapentin itself is the active substance in gabapentin medications.

    •  

  • FDA Approval: Lyrica is approved for treating fibromyalgia, neuropathic pain, seizures, and generalized anxiety disorder in certain regions. Gabapentin's primary uses are for seizures and nerve pain.

    •  

  • Potency and Dosing: Lyrica is often considered more potent, requiring lower doses to achieve similar effects compared to gabapentin.

    •  

  • Side Effects: Both can cause dizziness and fatigue, but the severity and other side effects can vary between individuals.

 

Can Lyrica help with anxiety?

 

Understanding Lyrica and Anxiety

 

  • Lyrica (pregabalin) is primarily approved for treating nerve pain, fibromyalgia, and seizures.

    •  

  • Although not FDA-approved for anxiety, it has been used off-label to help some patients manage anxiety symptoms, especially in generalized anxiety disorder (GAD).

 

Mechanism and Effectiveness

 

  • Lyrica works by calming hyper-excited nerves, which may reduce anxiety symptoms by stabilizing neuronal activity.

    •  

  • Clinical studies suggest it can reduce anxiety more effectively than a placebo and comparable to some anxiety medications.

 

Considerations and Side Effects

 

  • Possible side effects include dizziness, sleepiness, and weight gain, which should be considered before off-label use.

    •  

  • Consult your doctor to assess if Lyrica aligns with your specific health needs and to discuss alternate anxiety treatments.

 

Have questions left?

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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.

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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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Curex provides allergy care plans for allergies, asthma, eczema and pet allergies.

Curex providers may prescribe sublingual allergy drops that contain the same ingredients as allergy shots but are more convenient & affordable.
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