Does Gateway Health Plan Cover Saxenda

Explore why Gateway Health may deny Saxenda coverage, how to secure coverage, costs without insurance, and FAQs in this essential guide.
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Gateway Health Plan Coverage for Saxenda

 

  • Coverage for Saxenda may vary based on the specific Gateway Health Plan policy you hold. It is generally covered for chronic weight management.
  •  

  • **Eligibility Criteria:**
    • Designed for adults with a Body Mass Index (BMI) of 30 or higher.
    • Covered for individuals with a BMI of 27 or higher if they have weight-related health issues, such as hypertension, type 2 diabetes, or dyslipidemia.
  •  

  • **Prior Authorization:**
    • Verification required to ensure Saxenda's necessity for health conditions related to obesity.
  •  

  • **Prescription Requirements:**
    • Must be prescribed by a healthcare provider familiar with your health history and weight management needs.
  •  

  • Consult your policy details or contact Gateway Health Plan directly to confirm coverage, as terms and conditions may differ.

 

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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 Saxenda Coverage with Gateway Health Plan

 

Contact Gateway Health Plan Member Services

 

  • Reach out to the Gateway Health Plan member services. This initial contact is essential to get an understanding of the benefits and coverage options for medications like Saxenda.
  •  

  • Use the member services contact number on your insurance card or visit their website for more contact options.

 

Review Your Plan's Drug Coverage

 

  • Go through the details of your specific health plan to see if Saxenda is listed under the covered medications.
  •  

  • Check the plan's formulary, which is a list of prescription drugs covered by the health insurance plan, to see if Saxenda is included.

 

Consult with Your Healthcare Provider

 

  • Discuss with your healthcare provider the necessity of Saxenda for your treatment. Your provider may need to provide a medical justification for its use.
  •  

  • Your provider should be familiar with Gateway Health Plan requirements and can assist in ensuring that the necessary information is submitted for coverage approval.

 

Seek Prior Authorization

 

  • Many insurance plans, including Gateway Health Plan, may require prior authorization for Saxenda. This is a process where your healthcare provider submits a request to the insurance company justifying the need for the medication.
  •  

  • Work closely with your doctor to ensure that the prior authorization form is completed accurately and submitted promptly.

 

Follow Up on the Authorization Process

 

  • After submission, regularly follow up with both your healthcare provider’s office and Gateway Health Plan to check the status of your authorization.
  •  

  • If there are any delays or additional information needed, you will be informed promptly, allowing for faster processing.

 

Appeal If Necessary

 

  • If your initial request for coverage is denied, don’t hesitate to file an appeal. Gateway Health Plan typically provides instructions on how to file an appeal when they notify you of a denial.
  •  

  • Provide any additional documentation required, and work with your provider to strengthen the justification for the necessity of Saxenda.

 

Explore Patient Assistance Programs

 

  • If faced with difficulties getting Saxenda covered through Gateway Health Plan, consider contacting the manufacturer for patient assistance programs, which may offer the medication at a reduced cost or for free.
  •  

  • These programs often work alongside your insurance to ensure you receive your prescription affordably.

 

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FAQs

Does Gateway Health Plan Cover Saxenda

Explore why Gateway Health may deny Saxenda coverage, how to secure coverage, costs without insurance, and FAQs in this essential guide.
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Is Saxenda Covered by Gateway Health Plan

 

Gateway Health Plan Coverage for Saxenda

 

  • Coverage for Saxenda may vary based on the specific Gateway Health Plan policy you hold. It is generally covered for chronic weight management.
  •  

  • **Eligibility Criteria:**
    • Designed for adults with a Body Mass Index (BMI) of 30 or higher.
    • Covered for individuals with a BMI of 27 or higher if they have weight-related health issues, such as hypertension, type 2 diabetes, or dyslipidemia.
  •  

  • **Prior Authorization:**
    • Verification required to ensure Saxenda's necessity for health conditions related to obesity.
  •  

  • **Prescription Requirements:**
    • Must be prescribed by a healthcare provider familiar with your health history and weight management needs.
  •  

  • Consult your policy details or contact Gateway Health Plan directly to confirm coverage, as terms and conditions may differ.

 

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Gateway Health Plan's Approved Criteria for Saxenda Coverage

 

Eligibility Criteria for Saxenda Coverage

 

  • The patient must be an adult aged 18 or older.
  •  

  • The patient has a Body Mass Index (BMI) of 30 kg/m² or greater, qualifying as obese, or a BMI of 27 kg/m² or greater with at least one weight-related comorbidity such as type 2 diabetes, hypertension, or dyslipidemia.
  •  

  • The patient has previously attempted to manage weight through a structured weight loss program that includes physical activity and dietary changes.
  •  

  • A documented weight loss history supports the need for pharmacotherapy because non-pharmacological measures have proven insufficient.

 

Prescriber Requirements

 

  • The prescribing physician must be a specialist in endocrinology, obesity medicine, or have relevant experience in managing obesity.
  •  

  • A detailed treatment plan, including goals and monitoring measures for weight management, must be submitted by the prescriber.

 

Monitoring and Continued Coverage

 

  • Initial approval may be granted for a 3-month trial period, during which the patient must demonstrate adherence to the medication regimen and lifestyle modifications.
  •  

  • Continued coverage is contingent upon documentation showing a reduction of at least 5% of initial body weight at the end of the 12-week period from a reported start of treatment.
  •  

  • Regular follow-up through appointments and progress reports is required to evaluate the patient's adherence to therapy and overall weight management.

 

Additional Documentation

 

  • A letter of medical necessity written by the prescriber must be submitted, outlining the specific need for Saxenda based on the patient's medical history and any previous weight management treatments.
  •  

  • Patients may be required to provide authorization for accessing medical records to ensure compliance and progress tracking.

 

Why Gateway Health Plan Might Deny Saxenda Coverage

 

Reasons for Denial of Saxenda Coverage by Gateway Health Plan

 

  • Saxenda is not prescribed within the FDA-approved labeling, including recommended dosages and indications. Off-label use might lead to denial.
  •  

  • Failure to meet clinical criteria, such as specific body mass index (BMI) requirements, or not having qualifying weight-related comorbidities, may result in a rejection.
  •  

  • Lack of prior authorization or not submitting necessary documentation required by Gateway Health Plan can lead to a denial.
  •  

  • Previous attempts with lifestyle modifications such as diet and exercise are not documented or fail to show any evidence of efforts toward weight management.
  •  

  • Patients who have other contraindications or medical conditions that are specified as exclusions for coverage by Gateway Health Plan.
  •  

  • Prescriptions from providers outside the network or without proper referral may lead to non-coverage.
  •  

  • Non-compliance with the medical necessity criteria established by Gateway Health Plan for the use of Saxenda.

 

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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 Gateway Health Plan

 

Contact Gateway Health Plan Member Services

 

  • Reach out to the Gateway Health Plan member services. This initial contact is essential to get an understanding of the benefits and coverage options for medications like Saxenda.
  •  

  • Use the member services contact number on your insurance card or visit their website for more contact options.

 

Review Your Plan's Drug Coverage

 

  • Go through the details of your specific health plan to see if Saxenda is listed under the covered medications.
  •  

  • Check the plan's formulary, which is a list of prescription drugs covered by the health insurance plan, to see if Saxenda is included.

 

Consult with Your Healthcare Provider

 

  • Discuss with your healthcare provider the necessity of Saxenda for your treatment. Your provider may need to provide a medical justification for its use.
  •  

  • Your provider should be familiar with Gateway Health Plan requirements and can assist in ensuring that the necessary information is submitted for coverage approval.

 

Seek Prior Authorization

 

  • Many insurance plans, including Gateway Health Plan, may require prior authorization for Saxenda. This is a process where your healthcare provider submits a request to the insurance company justifying the need for the medication.
  •  

  • Work closely with your doctor to ensure that the prior authorization form is completed accurately and submitted promptly.

 

Follow Up on the Authorization Process

 

  • After submission, regularly follow up with both your healthcare provider’s office and Gateway Health Plan to check the status of your authorization.
  •  

  • If there are any delays or additional information needed, you will be informed promptly, allowing for faster processing.

 

Appeal If Necessary

 

  • If your initial request for coverage is denied, don’t hesitate to file an appeal. Gateway Health Plan typically provides instructions on how to file an appeal when they notify you of a denial.
  •  

  • Provide any additional documentation required, and work with your provider to strengthen the justification for the necessity of Saxenda.

 

Explore Patient Assistance Programs

 

  • If faced with difficulties getting Saxenda covered through Gateway Health Plan, consider contacting the manufacturer for patient assistance programs, which may offer the medication at a reduced cost or for free.
  •  

  • These programs often work alongside your insurance to ensure you receive your prescription affordably.

 

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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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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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