Does Fallon Community Health Plan (FCHP) Cover Saxenda

Explore FCHP's Saxenda coverage, reasons for denial, tips for approval, costs without insurance, and FAQs in one concise guide.
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Coverage for Saxenda

 

  • Fallon Community Health Plan (FCHP) may cover Saxenda for weight management under specific conditions.
  • Coverage typically applies to individuals with a Body Mass Index (BMI) of 30 or greater.
  • Coverage can also apply to individuals with a BMI of 27 or greater if they have at least one weight-related condition, such as hypertension, type 2 diabetes, or high cholesterol.
  • Prior authorization is usually required to confirm medical necessity before the prescription is approved.

 

Criteria and Requirements

 

  • A physician's documentation supporting the use of Saxenda based on medical history and weight-related issues might be necessary.
  • Patients may need to demonstrate previous attempts at weight loss through lifestyle changes such as diet and exercise programs.
  • FCHP often requires regular follow-ups to assess the medication’s effectiveness and the patient's adherence.
  • Continued coverage may depend on showing a sufficient clinical response within a specified time frame, commonly 12 weeks.

 

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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 Saxenda Coverage with Fallon Community Health Plan (FCHP)

 

Research Eligibility Criteria

 

  • Contact Fallon Community Health Plan (FCHP) or visit their official website to check the specific eligibility requirements for Saxenda coverage.
  • Ensure that Saxenda is a covered medication under your specific FCHP plan, as coverage may vary by plan type.
  • Determine if FCHP requires prior authorization or additional documentation for Saxenda.

 

Consult Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss your interest in Saxenda for weight management.
  • Verify that your healthcare provider is familiar with the process of obtaining insurance coverage for Saxenda.
  • Request your healthcare provider to provide the necessary medical justification and documentation supporting your need for Saxenda.

 

Contact Fallon Community Health Plan

 

  • Reach out to Fallon Community Health Plan’s customer service department via phone or email for guidance on coverage for Saxenda.
  • Inquire about the specific steps required to obtain prior authorization if needed.
  • Ask for a detailed list of all documents needed to process a coverage request for Saxenda.

 

Submit a Prior Authorization Request

 

  • Work with your healthcare provider to complete any prior authorization forms provided by FCHP.
  • Ensure that all necessary medical records and documentation, including BMI reports and previous weight management attempts, are included in the submission.
  • Submit the completed prior authorization request to FCHP as per their guidance.

 

Follow Up with FCHP

 

  • Regularly follow up with Fallon Community Health Plan to check the status of your prior authorization request.
  • Be prepared to provide any additional information or documentation if requested by FCHP during the review process.
  • Once approved, review the FCHP plan details for any copayments or coverage limitations related to Saxenda.

 

Understand Appeal Process

 

  • If your request for Saxenda coverage is denied, request detailed reasons for the denial from FCHP.
  • Work with your healthcare provider to address the denial reasons and gather additional supporting documentation.
  • Submit an appeal to FCHP, adhering to their specific appeal process and timelines.

 

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FAQs

Does Fallon Community Health Plan (FCHP) Cover Saxenda

Explore FCHP's Saxenda coverage, reasons for denial, tips for approval, costs without insurance, and FAQs in one concise guide.
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Is Saxenda Covered by Fallon Community Health Plan (FCHP)

 

Coverage for Saxenda

 

  • Fallon Community Health Plan (FCHP) may cover Saxenda for weight management under specific conditions.
  • Coverage typically applies to individuals with a Body Mass Index (BMI) of 30 or greater.
  • Coverage can also apply to individuals with a BMI of 27 or greater if they have at least one weight-related condition, such as hypertension, type 2 diabetes, or high cholesterol.
  • Prior authorization is usually required to confirm medical necessity before the prescription is approved.

 

Criteria and Requirements

 

  • A physician's documentation supporting the use of Saxenda based on medical history and weight-related issues might be necessary.
  • Patients may need to demonstrate previous attempts at weight loss through lifestyle changes such as diet and exercise programs.
  • FCHP often requires regular follow-ups to assess the medication’s effectiveness and the patient's adherence.
  • Continued coverage may depend on showing a sufficient clinical response within a specified time frame, commonly 12 weeks.

 

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

 

Criteria for Saxenda Coverage Under Fallon Community Health Plan (FCHP)

 

  • **Patient Diagnosis**: The patient must be diagnosed with obesity (BMI ≥30) or overweight (BMI ≥27) with at least one weight-related comorbidity such as hypertension, type 2 diabetes, or dyslipidemia.
  •  

  • **Age Requirement**: Saxenda coverage is approved for patients 18 years and older.
  •  

  • **Documentation of Previous Weight Management Efforts**: The patient must have documented evidence of previous comprehensive weight management efforts, including lifestyle changes, diet, and exercise, without satisfactory weight loss. These efforts should be supervised by a healthcare provider.
  •  

  • **Prescriber Criteria**: Saxenda must be prescribed by an endocrinologist, cardiologist, or healthcare providers with expertise in weight management.
  •  

  • **Medical Assessment**: A thorough medical assessment must be documented, including a history of obesity-related conditions, weight management programs, and assessment of potential contraindications for Saxenda use.
  •  

  • **Commitment to Lifestyle Changes**: The patient must be committed to maintaining a reduced-calorie diet and increasing physical activity as part of a long-term plan to manage weight.
  •  

  • **Monitoring Plan**: There should be a plan for regular follow-up and monitoring of weight loss progress and potential side effects. This includes scheduled visits with the prescribing healthcare provider to assess the efficacy and safety of Saxenda therapy.
  •  

  • **Continued Coverage Criteria**: After an initial treatment period, continued coverage of Saxenda requires documentation of clinically significant weight loss, typically at least 4% of baseline body weight, assessed after 16 weeks of therapy.
  •  

  • **Insurance Plan Requirements**: Saxenda may be subject to step therapy or prior authorization processes as per the specific plan details within Fallon Community Health Plan.

 

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

 

Criteria for Not Covering Saxenda

 

  • **Non-FDA Approved Usage**: Fallon Community Health Plan (FCHP) does not cover Saxenda when prescribed for conditions not approved by the FDA, such as weight maintenance or prevention.
  •  

  • **Lack of Medical Necessity**: If the patient’s medical condition does not warrant its necessity according to FCHP's medical guidelines, Saxenda coverage may be denied.
  •  

  • **Non-compliance with BMI Requirements**: Saxenda coverage might be denied if the individual does not meet specific body mass index (BMI) requirements set by FCHP.
  •  

  • **Failure to Complete Prior Therapies**: FCHP does not cover Saxenda if the patient has not tried and failed other weight management therapies as required.
  •  

  • **Age Restrictions**: Saxenda may not be covered if the patient is outside the approved age range for treatment.
  •  

  • **Excluded Conditions**: Coverage may be denied if the patient has exclusions such as a history of certain serious conditions like thyroid cancer.
  •  

  • **Lack of Required Documentation**: If proper documentation including medical history and previous treatment outcomes are not provided, FCHP may refuse Saxenda coverage.

 

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How Much Does Saxenda Cost without Insurance?

 

Approximate Cost of Saxenda Without Insurance

 

  • Saxenda is a prescription medication used to aid in weight loss and management for patients who are overweight or have obesity-related medical problems.
  •  

  • Without insurance, the cost of Saxenda can be substantial. Prices typically range from $1,200 to $1,500 for a 30-day supply, which consists of 3 pens.
  •  

  • The exact cost can vary based on the pharmacy you visit and potential discounts or coupons you may be able to use.
  •  

  • It's important to consider the long-term cost if Saxenda is prescribed for an extended period, as the monthly expense can add up significantly over time.
  •  

  • Some pharmacies may offer loyalty programs or discounts that can slightly reduce the cost, so it's advisable to shop around or inquire about savings programs.
  •  

  • Additionally, pharmaceutical assistance programs or patient assistance programs might be available for eligible patients to help minimize out-of-pocket 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 Saxenda Coverage with Fallon Community Health Plan (FCHP)

 

Research Eligibility Criteria

 

  • Contact Fallon Community Health Plan (FCHP) or visit their official website to check the specific eligibility requirements for Saxenda coverage.
  • Ensure that Saxenda is a covered medication under your specific FCHP plan, as coverage may vary by plan type.
  • Determine if FCHP requires prior authorization or additional documentation for Saxenda.

 

Consult Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss your interest in Saxenda for weight management.
  • Verify that your healthcare provider is familiar with the process of obtaining insurance coverage for Saxenda.
  • Request your healthcare provider to provide the necessary medical justification and documentation supporting your need for Saxenda.

 

Contact Fallon Community Health Plan

 

  • Reach out to Fallon Community Health Plan’s customer service department via phone or email for guidance on coverage for Saxenda.
  • Inquire about the specific steps required to obtain prior authorization if needed.
  • Ask for a detailed list of all documents needed to process a coverage request for Saxenda.

 

Submit a Prior Authorization Request

 

  • Work with your healthcare provider to complete any prior authorization forms provided by FCHP.
  • Ensure that all necessary medical records and documentation, including BMI reports and previous weight management attempts, are included in the submission.
  • Submit the completed prior authorization request to FCHP as per their guidance.

 

Follow Up with FCHP

 

  • Regularly follow up with Fallon Community Health Plan to check the status of your prior authorization request.
  • Be prepared to provide any additional information or documentation if requested by FCHP during the review process.
  • Once approved, review the FCHP plan details for any copayments or coverage limitations related to Saxenda.

 

Understand Appeal Process

 

  • If your request for Saxenda coverage is denied, request detailed reasons for the denial from FCHP.
  • Work with your healthcare provider to address the denial reasons and gather additional supporting documentation.
  • Submit an appeal to FCHP, adhering to their specific appeal process and timelines.

 

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Saxenda FAQ

1. How much weight can you lose with Saxenda?

 

Expected Weight Loss with Saxenda

 

  • According to clinical studies, Saxenda helps achieve significant weight loss; patients can expect to lose around 5% to 10% of their initial body weight.
  •  

  • The average weight loss in clinical trials was approximately 8%, but individual results can vary based on several factors including diet and exercise.
  •  

  • For some, weight loss may exceed 10%, while others may experience less than 5% reduction.
  •  

  • Adopt lifestyle changes alongside Saxenda, like improved diet and increased physical activity, to maximize weight loss.
  •  

 

2. What are the common side effects of Saxenda?

 

Common Side Effects of Saxenda

 

  • Nausea: This is the most frequently reported side effect, often decreasing over time as the body adjusts.
  •  

  • Diarrhea: Changes in bowel habits, including diarrhea, are possible but usually manageable.
  •  

  • Constipation: Some patients experience constipation, a common gastrointestinal effect.
  •  

  • Vomiting: Vomiting can occur, especially in the initial stages of treatment.
  •  

  • Headache: Many patients report headaches, though these often lessen as treatment progresses.
  •  

  • Dizziness: Feeling lightheaded or dizzy can accompany Saxenda use.
  •  

  • Fatigue: Tiredness or fatigue is commonly noted but tends to be temporary.
  •  

  • Injection Site Reactions: Redness or irritation at the injection site may occur.

 

3. How long does it take for Saxenda to start working?

 

How Saxenda Works

 

  • Saxenda is a GLP-1 receptor agonist, which works by decreasing appetite and caloric intake.
  •  

  • The onset of its effects can vary among individuals.

 

Timeframe for Effects

 

  • Patients may start experiencing decreased appetite within the first week of treatment.
  •  

  • Noticeable weight loss usually begins after 4-8 weeks, especially when combined with a reduced-calorie diet and increased physical activity.

 

Monitoring Progress

 

  • Regular follow-ups with your healthcare provider are essential to assess progress and adjust the dosage if necessary.
  •  

  • Adherence to lifestyle changes significantly enhances results with Saxenda.

 

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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.

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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.

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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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