Does Gateway Health Plan Cover Tirzepatide (Mounjaro)

Explore Gateway Health Plan's coverage of Tirzepatide (Mounjaro), the reasons for denial, ways to secure coverage, cost concerns, and FAQs.
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Gateway Health Plan Coverage for Tirzepatide (Mounjaro)

 

  • Tirzepatide (Mounjaro) is typically prescribed for managing type 2 diabetes.
  •  

  • Gateway Health Plan may cover Tirzepatide if it is deemed medically necessary by the prescriber.
  •  

  • Coverage usually requires prior authorization, meaning a physician must justify the need through documentation.

 

Criteria for Coverage

 

  • Patients must have a diagnosis of type 2 diabetes.
  •  

  • Documentation of previous failure or intolerance to other diabetes medications might be required.
  •  

  • Demonstrating significant health benefit over existing treatments can support the case.

 

Basic Rules and Requirements

 

  • Ensure your healthcare provider submits the necessary documentation and rationale.
  •  

  • Check specific formulary details with Gateway Health Plan to confirm Mounjaro's status.
  •  

  • Regular follow-ups with your healthcare provider can aid in securing continued coverage.

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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.

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 Tirzepatide (Mounjaro) Coverage with Gateway Health Plan

 

Contact Gateway Health Plan Customer Service

 

  • Reach out to Gateway Health Plan's customer service to inquire about coverage for Tirzepatide (Mounjaro). This will help you understand any specific requirements or restrictions they may have in place.
  •  

  • Gather information on your current plan details to discuss how coverage can be applied or what changes might be necessary.

 

Consult with Your Healthcare Provider

 

  • Discuss with your healthcare provider about the medical necessity of Tirzepatide for your treatment. They can provide medical documentation and support your case for insurance coverage.
  •  

  • Ensure your healthcare provider is prepared to communicate with Gateway Health Plan, if needed, to answer any medical questions they may have.

 

Check for Prior Authorization Requirements

 

  • Verify if Gateway Health Plan requires prior authorization for Tirzepatide. This step is crucial as it helps avoid unexpected denial of claims.
  •  

  • Work with your healthcare provider to submit necessary documentation, which might include your medical history, diagnosis, and treatment plan.

 

Review Formularies and Drug Tiers

 

  • Examine Gateway Health Plan's formulary list to see where Tirzepatide is categorized. This can impact your out-of-pocket costs significantly.
  •  

  • If needed, consider discussing alternative therapies with your healthcare provider that are covered under a different tier if Mounjaro is not covered.

 

Submit a Coverage Request

 

  • If Tirzepatide is not covered by your plan, consider submitting a formal coverage request or exception. Provide medical documentation and evidence why this treatment is necessary.
  •  

  • Be persistent and keep records of all your communications with both Gateway Health Plan and your healthcare provider regarding this request.

 

Appeal Denied Claims, if Necessary

 

  • If your initial request is denied, study the explanation of benefits (EOB) provided to understand the reason for denial.
  •  

  • Work with your healthcare provider to address the denial reasons and submit an appeal. Include all relevant documentation to support your case.

 

Explore Additional Financial Assistance Programs

 

  • Look into patient assistance programs or savings cards offered by the manufacturer of Tirzepatide, as they may help offset costs if insurance coverage is insufficient.
  •  

  • Check if there are any state or nonprofit programs available that could provide additional financial support for your prescription.

 

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FAQs

Does Gateway Health Plan Cover Tirzepatide (Mounjaro)

Explore Gateway Health Plan's coverage of Tirzepatide (Mounjaro), the reasons for denial, ways to secure coverage, cost concerns, and FAQs.
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Is Tirzepatide (Mounjaro) Covered by Gateway Health Plan

 

Gateway Health Plan Coverage for Tirzepatide (Mounjaro)

 

  • Tirzepatide (Mounjaro) is typically prescribed for managing type 2 diabetes.
  •  

  • Gateway Health Plan may cover Tirzepatide if it is deemed medically necessary by the prescriber.
  •  

  • Coverage usually requires prior authorization, meaning a physician must justify the need through documentation.

 

Criteria for Coverage

 

  • Patients must have a diagnosis of type 2 diabetes.
  •  

  • Documentation of previous failure or intolerance to other diabetes medications might be required.
  •  

  • Demonstrating significant health benefit over existing treatments can support the case.

 

Basic Rules and Requirements

 

  • Ensure your healthcare provider submits the necessary documentation and rationale.
  •  

  • Check specific formulary details with Gateway Health Plan to confirm Mounjaro's status.
  •  

  • Regular follow-ups with your healthcare provider can aid in securing continued coverage.

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Gateway Health Plan's Approved Criteria for Tirzepatide (Mounjaro) Coverage

 

Eligibility Requirements

 

  • Patient must have a diagnosis of Type 2 diabetes.
  •  

  • Must be 18 years of age or older.
  •  

  • Patient should have demonstrated an inadequate response or intolerance to at least one other anti-diabetic medication, such as metformin, unless contraindicated.

 

Clinical Criteria

 

  • Documentation of patient’s current HbA1c level is required and must be greater than or equal to 7%.
  •  

  • Body Mass Index (BMI) should be recorded, and criteria may include those with a BMI of 30 kg/m2 or greater, or 27 kg/m2 or greater with weight-related comorbid conditions.
  •  

  • Tirzepatide should be used as part of a comprehensive diabetes care plan, which includes diet and exercise.

 

Physician Requirements

 

  • Prescribing physician must be an endocrinologist or specialist in managing diabetes, or in consultation with one.
  •  

  • Documentation supporting the necessity for the prescription should be provided by the attending healthcare provider.

 

Continuing Coverage Criteria

 

  • Clinical assessment after initial 3 to 6 months of treatment demonstrating a reduction in HbA1c levels.
  •  

  • Evidence of compliance with the treatment regimen, diet, and exercise plan.
  •  

  • No significant adverse effects that may lead to discontinuation.

 

Renewal Criteria

 

  • Continued improvement or stabilization of HbA1c levels under 7%.
  •  

  • Updated documentation from the prescribing physician detailing ongoing benefit from Tirzepatide therapy.
  •  

  • Proof of routine engagement with diabetes management plan.

 

Why Gateway Health Plan Might Deny Tirzepatide (Mounjaro) Coverage

 

Reasons for Denial of Tirzepatide (Mounjaro) Coverage by Gateway Health Plan

 

  • Lack of Medical Necessity: The request for Tirzepatide may be denied if Gateway Health Plan determines that it is not medically necessary based on the provided patient information.
  •  

  • Non-Compliance with Prior Authorization: Failure to obtain prior authorization before prescribing Tirzepatide can result in coverage denial. Prior authorization is typically required to assess medical necessity and adherence to clinical guidelines.
  •  

  • Off-Label Use: If Tirzepatide is prescribed for an indication not approved by the FDA or outside the accepted clinical guidelines, Gateway Health Plan may deny coverage.
  •  

  • Patient Not Meeting Clinical Criteria: Patients must meet specific clinical criteria set by Gateway Health Plan. Coverage may be denied if these criteria, such as specific diagnosis requirements or BMI thresholds, are not met.
  •  

  • Formulary Restrictions: Tirzepatide may not be included in Gateway Health Plan’s preferred drug formulary. If it is not on the list of covered drugs, a request might be denied unless an exception is approved.
  •  

  • Failure to Try Alternative Treatments: Denial may occur if the patient has not attempted or shown intolerance to alternative, less expensive treatments before attempting Tirzepatide.
  •  

  • Lack of Updated Documentation: Incomplete or outdated medical records and documentation can lead to a denial of coverage for Tirzepatide. Up-to-date clinical information is crucial for evaluation.
  •  

 

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How Much Does Tirzepatide (Mounjaro) Cost without Insurance?

 

Cost of Tirzepatide (Mounjaro) Without Insurance

 

  • The approximate cost of Tirzepatide, commonly known by its brand name Mounjaro, can vary based on several factors including the pharmacy location and any available discounts.
  •  

  • On average, the price for four doses of Mounjaro, which is typically a one-month supply, is estimated to be between $1,000 and $1,250 without any insurance coverage.
  •  

  • It's essential for patients to check with different pharmacies and consider available savings programs or manufacturer coupons which might offer significant reductions or discounts.
  •  

  • Additionally, some pharmacies might provide membership programs or discount cards that could further lower the 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 Tirzepatide (Mounjaro) Coverage with Gateway Health Plan

 

Contact Gateway Health Plan Customer Service

 

  • Reach out to Gateway Health Plan's customer service to inquire about coverage for Tirzepatide (Mounjaro). This will help you understand any specific requirements or restrictions they may have in place.
  •  

  • Gather information on your current plan details to discuss how coverage can be applied or what changes might be necessary.

 

Consult with Your Healthcare Provider

 

  • Discuss with your healthcare provider about the medical necessity of Tirzepatide for your treatment. They can provide medical documentation and support your case for insurance coverage.
  •  

  • Ensure your healthcare provider is prepared to communicate with Gateway Health Plan, if needed, to answer any medical questions they may have.

 

Check for Prior Authorization Requirements

 

  • Verify if Gateway Health Plan requires prior authorization for Tirzepatide. This step is crucial as it helps avoid unexpected denial of claims.
  •  

  • Work with your healthcare provider to submit necessary documentation, which might include your medical history, diagnosis, and treatment plan.

 

Review Formularies and Drug Tiers

 

  • Examine Gateway Health Plan's formulary list to see where Tirzepatide is categorized. This can impact your out-of-pocket costs significantly.
  •  

  • If needed, consider discussing alternative therapies with your healthcare provider that are covered under a different tier if Mounjaro is not covered.

 

Submit a Coverage Request

 

  • If Tirzepatide is not covered by your plan, consider submitting a formal coverage request or exception. Provide medical documentation and evidence why this treatment is necessary.
  •  

  • Be persistent and keep records of all your communications with both Gateway Health Plan and your healthcare provider regarding this request.

 

Appeal Denied Claims, if Necessary

 

  • If your initial request is denied, study the explanation of benefits (EOB) provided to understand the reason for denial.
  •  

  • Work with your healthcare provider to address the denial reasons and submit an appeal. Include all relevant documentation to support your case.

 

Explore Additional Financial Assistance Programs

 

  • Look into patient assistance programs or savings cards offered by the manufacturer of Tirzepatide, as they may help offset costs if insurance coverage is insufficient.
  •  

  • Check if there are any state or nonprofit programs available that could provide additional financial support for your prescription.

 

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Tirzepatide (Mounjaro) FAQ

What are common side effects of Tirzepatide (Mounjaro)?

 

Common Side Effects of Tirzepatide (Mounjaro)

 

  • Nausea: Frequently reported, especially when starting treatment or increasing the dose.
  •  

  • Diarrhea: Some patients experience loose stools during treatment.
  •  

  • Decreased Appetite: Commonly occurs and can aid in weight management.
  •  

  • Vomiting: May happen occasionally, often alongside nausea.
  •  

  • Constipation: Some individuals might experience slower bowel movements.
  •  

  • Abdominal Pain: Discomfort or pain may occur during therapy.
  •  

  • Fatigue: A feeling of tiredness or exhaustion might present itself in some users.
  •  

  • In rare cases, hypoglycemia occurs, especially if combined with insulin or sulfonylureas.

 

How does Tirzepatide (Mounjaro) help with weight loss?

 

How Tirzepatide Aids Weight Loss

 

  • Dual Agonist Action: Tirzepatide acts on both GLP-1 and GIP receptors. These hormones help regulate appetite and glucose, influencing energy balance and metabolism.
  •  

  • Appetite Suppression: By mimicking these hormones, it reduces hunger, promoting lower calorie intake.
  •  

  • Increased Satiety: Delays gastric emptying, enhancing fullness and reducing meal frequency.
  •  

  • Improved Blood Sugar Control: Helps stabilize blood glucose levels, reducing insulin spikes that can stimulate hunger.
  •  

  • Enhanced Energy Expenditure: Modulates metabolic pathways to increase calorie burning, aiding fat loss.

 

Is Tirzepatide (Mounjaro) the same as Ozempic or Wegovy?

 

Comparing Tirzepatide with Ozempic and Wegovy

 

  • Composition: Tirzepatide (Mounjaro), Ozempic, and Wegovy are different medications. Tirzepatide is a dual GIP and GLP-1 receptor agonist, whereas Ozempic and Wegovy contain semaglutide, a GLP-1 receptor agonist.
  •  

  • Indications: Both Ozempic and Mounjaro target type 2 diabetes, but Wegovy is approved mainly for chronic weight management.
  •  

  • Mechanism: All induce insulin secretion and appetite suppression, yet Mounjaro's dual action may offer distinct benefits in glucose control and weight loss.
  •  

  • Dosage and Administration: Dosage forms and protocols vary; always follow medical guidance specific to the prescribed drug.
  •  

  • Considerations: Always consult your healthcare provider to determine the best option based on personal health needs and conditions.

 

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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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