Does Geisinger Health Plan Cover Tirzepatide (Mounjaro)

Explore Geisinger Health Plan's coverage for Tirzepatide (Mounjaro), potential denial reasons, costs without insurance, and FAQs for better understanding.
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Geisinger Health Plan Coverage for Tirzepatide (Mounjaro)

 

  • Geisinger Health Plan may cover Tirzepatide (Mounjaro) for specific medical conditions such as type 2 diabetes, subject to plan details and approval.
  •  

  • Coverage typically requires prior authorization, meaning patients must get approval before the medication is dispensed.
  •  

  • Patients generally need to provide evidence of previous treatment failures or specific medical criteria to qualify for coverage. This is determined by clinical guidelines and the plan’s specific policy.
  •  

  • Geisinger Health Plan might also require that Tirzepatide be prescribed by a specialist, such as an endocrinologist.
  •  

  • Covered prescriptions may have a copayment or be subject to a deductible, depending on the specific health plan.

 

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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 Geisinger Health Plan

 

Check Your Eligibility

 

  • Review the benefits of your Geisinger Health Plan to determine if prescription coverage includes medications like Tirzepatide (Mounjaro). Check the member handbook or the plan's online portal for details.
  •  

  • Ensure that your specific condition qualifies for coverage of Tirzepatide under the plan. Usually, this medication is prescribed for managing type 2 diabetes or associated health issues.
  •  

 

Consult Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss your condition and the potential benefits of starting Tirzepatide (Mounjaro).
  •  

  • Request the necessary medical documentation that supports the need for the prescription. This may include current treatment results, lab tests, and a summary of your condition.
  •  

  • Ask your provider to write a prescription for Tirzepatide, with any additional notes or documentation needed for insurance purposes.
  •  

 

Contact Geisinger Health Plan

 

  • Call the customer service number on your insurance card to inquire specifically about coverage for Tirzepatide (Mounjaro). Have your plan details on hand to discuss available benefits and requirements.
  •  

  • Ask about any prior authorization that might be needed and inquire about the necessary steps for submitting documentation.
  •  

  • Request information on copay amounts or out-of-pocket expenses that may apply to Tirzepatide under your plan.
  •  

 

Submit Required Documentation

 

  • Compile the necessary documents including your prescription, any medical documentation provided by your healthcare provider, and the prior authorization form if required.
  •  

  • Submit these documents through the method specified by Geisinger - typically via mail, fax, or online submission through their member portal.
  •  

  • Keep a copy of all submissions for your records, noting the date and method of submission.
  •  

 

Follow Up

 

  • Contact Geisinger Health Plan a few days after submission to confirm receipt of your documents and to check on the status of your request.
  •  

  • Be prepared to provide any additional information promptly if requested by the insurer.
  •  

  • Once approved, confirm the details of the coverage, including any copayments or additional costs, and fill your prescription at a participating pharmacy.
  •  

 

Appeal if Necessary

 

  • If your request for coverage is denied, review the denial letter carefully to understand the reason and the appeals process.
  •  

  • Gather additional documentation that might support your case, potentially including another letter from your healthcare provider.
  •  

  • Submit an appeal following the guidelines provided, maintaining communication with Geisinger Health Plan until a final decision is reached.
  •  

 

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FAQs

Does Geisinger Health Plan Cover Tirzepatide (Mounjaro)

Explore Geisinger Health Plan's coverage for Tirzepatide (Mounjaro), potential denial reasons, costs without insurance, and FAQs for better understanding.
Curex allergy drops unboxing

Is Tirzepatide (Mounjaro) Covered by Geisinger Health Plan

 

Geisinger Health Plan Coverage for Tirzepatide (Mounjaro)

 

  • Geisinger Health Plan may cover Tirzepatide (Mounjaro) for specific medical conditions such as type 2 diabetes, subject to plan details and approval.
  •  

  • Coverage typically requires prior authorization, meaning patients must get approval before the medication is dispensed.
  •  

  • Patients generally need to provide evidence of previous treatment failures or specific medical criteria to qualify for coverage. This is determined by clinical guidelines and the plan’s specific policy.
  •  

  • Geisinger Health Plan might also require that Tirzepatide be prescribed by a specialist, such as an endocrinologist.
  •  

  • Covered prescriptions may have a copayment or be subject to a deductible, depending on the specific health plan.

 

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

 

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

 

  • Member must be 18 years of age or older.
  •  

  • The member has a diagnosis of Type 2 Diabetes Mellitus as confirmed through medical documentation.
  •  

  • Member must have a documented trial and inadequate response, contraindication, or intolerance to a combination of at least two oral anti-diabetic medications.
  •  

  • Documentation of member's HbA1c levels indicating inadequate glycemic control despite the current anti-diabetic regimen.
  •  

  • A comprehensive metabolic panel should be provided to support medical necessity for initiating treatment with Tirzepatide.
  •  

  • The treatment should be prescribed by or in consultation with an endocrinologist or a healthcare provider specializing in diabetes management.
  •  

  • Member should be enrolled in a diabetes self-management education program and a monitoring plan as recommended by healthcare professionals.
  •  

  • Member must not have any known contraindications to the use of Tirzepatide.
  •  

  • Treatment with Tirzepatide is to be used as an adjunct to diet and exercise to improve glycemic control.
  •  

 

Prior Authorization Requirement

 

  • Prior authorization is required for coverage, and the prescriber must submit the necessary clinical information to justify the medical necessity of Tirzepatide therapy.
  •  

  • Regular documentation of clinical response to therapy is needed for ongoing approval of Tirzepatide coverage.
  •  

  • Reauthorization request should include recent HbA1c results demonstrating the effectiveness of Tirzepatide in improving glycemic control.
  •  

 

Renewal Criteria

 

  • Positive clinical response indicated by a reduction in HbA1c levels from baseline.
  •  

  • Continued adherence to prescribed diet and exercise regimen for diabetes management.
  •  

  • Absence of significant adverse effects that would necessitate discontinuation of therapy.
  •  

  • Provider attestation of the member's ongoing benefit from Tirzepatide therapy.
  •  

 

Why Geisinger Health Plan Might Deny Tirzepatide (Mounjaro) Coverage

 

Circumstances When Geisinger Health Plan Might Deny Coverage for Tirzepatide (Mounjaro)

 

  • If the prescription is not within the approved therapeutic guidelines or indications set by the Geisinger Health Plan.
  •  

  • When used outside the constraints of FDA-approved indications for Tirzepatide, such as for conditions Geisinger Health Plan does not recognize as apropos for coverage.
  •  

  • In cases where the patient does not meet the specific clinical criteria established by Geisinger Health Plan, including but not limited to either minimum or maximum BMI requirements or other health-related criteria.
  •  

  • Lack of prior authorization, if required by the plan, which could result in a denial of coverage.
  •  

  • If the prescription is written by a healthcare provider not in the Geisinger Health Plan network or not approved by the plan for prescribing specialty medications like Tirzepatide.
  •  

  • When there is insufficient documentation provided to support the medical necessity of Tirzepatide (Mounjaro) according to the plan's policy.
  •  

  • If there is a failure to adhere to step therapy protocols or trial of alternative treatments as required by the Geisinger Health Plan.
  •  

  • In situations where the patient has not demonstrated the required previous unsuccessful attempts on other lower-cost medications or therapies, where policy dictates such trials must occur first.
  •  

  • Failure to comply with any Geisinger Health Plan specific safety checks or additional monitoring criteria required for the use of Tirzepatide.
  •  

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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 Geisinger Health Plan

 

Check Your Eligibility

 

  • Review the benefits of your Geisinger Health Plan to determine if prescription coverage includes medications like Tirzepatide (Mounjaro). Check the member handbook or the plan's online portal for details.
  •  

  • Ensure that your specific condition qualifies for coverage of Tirzepatide under the plan. Usually, this medication is prescribed for managing type 2 diabetes or associated health issues.
  •  

 

Consult Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss your condition and the potential benefits of starting Tirzepatide (Mounjaro).
  •  

  • Request the necessary medical documentation that supports the need for the prescription. This may include current treatment results, lab tests, and a summary of your condition.
  •  

  • Ask your provider to write a prescription for Tirzepatide, with any additional notes or documentation needed for insurance purposes.
  •  

 

Contact Geisinger Health Plan

 

  • Call the customer service number on your insurance card to inquire specifically about coverage for Tirzepatide (Mounjaro). Have your plan details on hand to discuss available benefits and requirements.
  •  

  • Ask about any prior authorization that might be needed and inquire about the necessary steps for submitting documentation.
  •  

  • Request information on copay amounts or out-of-pocket expenses that may apply to Tirzepatide under your plan.
  •  

 

Submit Required Documentation

 

  • Compile the necessary documents including your prescription, any medical documentation provided by your healthcare provider, and the prior authorization form if required.
  •  

  • Submit these documents through the method specified by Geisinger - typically via mail, fax, or online submission through their member portal.
  •  

  • Keep a copy of all submissions for your records, noting the date and method of submission.
  •  

 

Follow Up

 

  • Contact Geisinger Health Plan a few days after submission to confirm receipt of your documents and to check on the status of your request.
  •  

  • Be prepared to provide any additional information promptly if requested by the insurer.
  •  

  • Once approved, confirm the details of the coverage, including any copayments or additional costs, and fill your prescription at a participating pharmacy.
  •  

 

Appeal if Necessary

 

  • If your request for coverage is denied, review the denial letter carefully to understand the reason and the appeals process.
  •  

  • Gather additional documentation that might support your case, potentially including another letter from your healthcare provider.
  •  

  • Submit an appeal following the guidelines provided, maintaining communication with Geisinger Health Plan until a final decision is reached.
  •  

 

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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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Initial Dosage

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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