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Does Harvard Pilgrim Health Care Cover Farxiga

Discover why Harvard Pilgrim might deny Farxiga, how to obtain coverage, its cost without insurance, and answers to common questions in this informative guide.
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Coverage for Farxiga

 

  • Harvard Pilgrim Health Care generally covers Farxiga, a medication prescribed for managing type 2 diabetes and heart failure.

    •  

  • Coverage typically applies if Farxiga is medically necessary and prescribed by a healthcare professional.

 

Criteria for Coverage

 

  • Patients may need a prior authorization from Harvard Pilgrim to ensure the medication is necessary.

    •  

  • It must be prescribed for approved medical conditions like type 2 diabetes or specific heart failure cases.

    •  

  • Follow pharmacy benefit program rules and check formulary status to confirm coverage.

 

Steps to Ensure Coverage

 

  • Discuss with your healthcare provider about the necessity and suitability of Farxiga for your condition.

    •  

  • Ensure that all required documentation and prior authorizations are submitted by your healthcare provider.

    •  

  • Contact Harvard Pilgrim directly to confirm specific details about co-pays or out-of-pocket costs.

 

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Clinical Support

Our team is here to help!

Dr. Neeta Ogden, MD

Curex is poised to revolutionize the way allergies are treated in America, expanding access to clinical care and treatments that can meaningfully improve patients quality of life.

Dr. Ravi Patel, VP Telemedicine

At Curex, our mission is to help people improve their health and quality of life by understanding their allergies and treating them at their source.We provide more than individualized prescription treatments; we provide individualized care.

Jill Hamburg, PA - C

Immunotherapy made simple.  We enable patients to receive personalized allergy care on their own time. No more waiting rooms.

Dr. Chet Tharpe, Medical Director

Curex has set the standard for the virtual allergy experience. From the comfort of their home, patients nationwide are able to receive a personalized treatment plan from an experienced clinician, aimed at treating the source of their allergies, not just the symptoms.

Kayla Mardaga, NP

Curex offers convenient at-home allergy testing options. Our goal is to determine if a patient would benefit from immunotherapy and then customize a treatment plan that can reduce both the symptoms and the reliance on allergy medications.

How to Get Farxiga Coverage with Harvard Pilgrim Health Care

 

Start with Understanding Coverage Requirements

 

  • Review your Harvard Pilgrim Health Care plan documents to understand prescription drug coverage specifics.
  • Check the formulary list provided by Harvard Pilgrim to see if Farxiga is part of the covered medications.
  • Ensure you're aware of any coverage restrictions, such as prior authorization or step therapy.

 

Consult Your Healthcare Provider

 

  • Speak with your healthcare provider about the necessity of Farxiga for your treatment plan.
  • Request that your healthcare provider writes a prescription for Farxiga clearly indicating the medical necessity.

 

Contact Harvard Pilgrim Member Services

 

  • Call the member services number on your Harvard Pilgrim member card for more information about your prescription drug coverage.
  • Ask about specific requirements for Farxiga, such as prior authorization or whether it's included in the formulary.
  • Inquire about any potential alternatives covered if Farxiga is not directly covered.

 

Follow the Prior Authorization Process

 

  • If Farxiga requires prior authorization, work with your healthcare provider to submit the necessary forms to Harvard Pilgrim.
  • Ensure the submission includes detailed information on why Farxiga is necessary for your treatment.
  • Be prepared to provide additional information if requested by Harvard Pilgrim during the review process.

 

Explore Appeals Process if Necessary

 

  • If your request for coverage is denied, review the denial letter from Harvard Pilgrim for details on the appeals process.
  • Compile documentation supporting the medical necessity of Farxiga, including healthcare provider letters and medical records.
  • Submit an appeal according to Harvard Pilgrim's specified procedures, ensuring all deadlines are met.

 

Explore Assistance Programs

 

  • If coverage challenges persist, consider exploring manufacturer assistance programs for Farxiga.
  • Contact the manufacturer directly or through your healthcare provider to inquire about patient assistance programs or discount cards.

 

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FAQs

Does Harvard Pilgrim Health Care Cover Farxiga

Discover why Harvard Pilgrim might deny Farxiga, how to obtain coverage, its cost without insurance, and answers to common questions in this informative guide.
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Is Farxiga Covered by Harvard Pilgrim Health Care

 

Coverage for Farxiga

 

  • Harvard Pilgrim Health Care generally covers Farxiga, a medication prescribed for managing type 2 diabetes and heart failure.

    •  

  • Coverage typically applies if Farxiga is medically necessary and prescribed by a healthcare professional.

 

Criteria for Coverage

 

  • Patients may need a prior authorization from Harvard Pilgrim to ensure the medication is necessary.

    •  

  • It must be prescribed for approved medical conditions like type 2 diabetes or specific heart failure cases.

    •  

  • Follow pharmacy benefit program rules and check formulary status to confirm coverage.

 

Steps to Ensure Coverage

 

  • Discuss with your healthcare provider about the necessity and suitability of Farxiga for your condition.

    •  

  • Ensure that all required documentation and prior authorizations are submitted by your healthcare provider.

    •  

  • Contact Harvard Pilgrim directly to confirm specific details about co-pays or out-of-pocket costs.

 

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Harvard Pilgrim Health Care's Approved Criteria for Farxiga Coverage

 

Criteria for Farxiga Coverage by Harvard Pilgrim Health Care

 

  • The patient must have a diagnosis of Type 2 Diabetes Mellitus and a documented need to improve glycemic control, in addition to lifestyle modifications such as diet and exercise.

    •  

  • Farxiga can be considered for patients who exhibit contraindications or have experienced intolerance to other oral antidiabetic agents such as metformin.

    •  

  • For patients with Heart Failure, Farxiga may be approved if the patient has a left ventricular ejection fraction of 40% or less, regardless of diabetes status.

    •  

  • Patients with Chronic Kidney Disease may qualify for Farxiga coverage if they meet criteria regarding the severity of kidney function impairment and benefits outweigh risks as determined by the prescribing healthcare provider.

    •  

  • The prescribing clinician must provide evidence or documentation of treatment plans and adherence to prior therapy protocols that are ineffective, contraindicated, or pose safety issues.

    •  

  • Patients are generally expected to undergo periodic efficacy assessments which demonstrate continued benefit from Farxiga treatment.

    •  

  • The prescribing healthcare professional must document that Farxiga will be used in combination with other antidiabetic medications for optimal therapeutic outcomes unless contraindications exist.

 

Additional Considerations

 

  • Approval may require specific formulary exception requests supported by clinical evidence or specialist input when necessary.

    •  

  • Requirements for dosage adjustment based on individual patient profiles, with particular attention to intercurrent conditions affecting drug metabolism, should be outlined in the application for coverage.

    •  

  • Periodical re-evaluation may be required, covering aspects such as patient health status, potential drug interactions, and emergent side effects.

 

Why Harvard Pilgrim Health Care Might Deny Farxiga Coverage

 

Reasons for Denial of Farxiga Coverage

 

  • Prescription Without a Confirmed Diagnosis: Farxiga may not be covered if prescribed without a confirmed diagnosis of the specific conditions it is approved to treat, such as type 2 diabetes, heart failure, or chronic kidney disease.

    •  

  • Off-label Use: If Farxiga is prescribed for a condition or use not approved by the FDA, Harvard Pilgrim may deny coverage due to the lack of evidence-based support for that particular use.

    •  

  • Non-Compliance with Prior Authorization: Coverage could be denied if prior authorization requirements are not met. This includes providing necessary documentation or failing to obtain approval before the prescription is filled.

    •  

  • Alternative Treatments Available: If less expensive generic alternatives or other medications with similar efficacy are available, the plan might deny Farxiga coverage to encourage cost-effective treatment options.

    •  

  • Non-Formulary Medication: Farxiga might not be included in the specific formulary or drug list covered by the member's plan, leading to a denial of coverage unless an exception is granted.

    •  

  • Lack of Step Therapy Compliance: Harvard Pilgrim may require members to try other designated first-line medications before covering Farxiga. Failure to demonstrate step therapy compliance can result in denied coverage.

    •  

  • Exceeding Quantity Limits: If a prescription exceeds the plan's quantity limits for Farxiga, coverage may be denied unless an exception request is approved.

 

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How Much Does Farxiga Cost without Insurance?

 

Estimated Cost of Farxiga Without Insurance

 

  • Farxiga, a medication used primarily for the management of type 2 diabetes and certain forms of heart failure, can be quite costly without insurance coverage.

    •  

  • The cash price for Farxiga typically ranges between $500 and $550 for a 30-day supply, depending on the pharmacy and location.

    •  

  • Some pharmacies may offer discount programs or cards that can slightly lower this cost, but significant savings are usually only available through insurance coverage.

    •  

  • Always consider checking with multiple pharmacies or online services where discounts might be more prevalent.

 

Clinical Support

Our team is here to help!

Dr. Neeta Ogden, MD

Curex is poised to revolutionize the way allergies are treated in America, expanding access to clinical care and treatments that can meaningfully improve patients quality of life.

Dr. Ravi Patel, VP Telemedicine

At Curex, our mission is to help people improve their health and quality of life by understanding their allergies and treating them at their source.We provide more than individualized prescription treatments; we provide individualized care.

Jill Hamburg, PA - C

Immunotherapy made simple.  We enable patients to receive personalized allergy care on their own time. No more waiting rooms.

Dr. Chet Tharpe, Medical Director

Curex has set the standard for the virtual allergy experience. From the comfort of their home, patients nationwide are able to receive a personalized treatment plan from an experienced clinician, aimed at treating the source of their allergies, not just the symptoms.

Kayla Mardaga, NP

Curex offers convenient at-home allergy testing options. Our goal is to determine if a patient would benefit from immunotherapy and then customize a treatment plan that can reduce both the symptoms and the reliance on allergy medications.

How to Get Farxiga Coverage with Harvard Pilgrim Health Care

 

Start with Understanding Coverage Requirements

 

  • Review your Harvard Pilgrim Health Care plan documents to understand prescription drug coverage specifics.
  • Check the formulary list provided by Harvard Pilgrim to see if Farxiga is part of the covered medications.
  • Ensure you're aware of any coverage restrictions, such as prior authorization or step therapy.

 

Consult Your Healthcare Provider

 

  • Speak with your healthcare provider about the necessity of Farxiga for your treatment plan.
  • Request that your healthcare provider writes a prescription for Farxiga clearly indicating the medical necessity.

 

Contact Harvard Pilgrim Member Services

 

  • Call the member services number on your Harvard Pilgrim member card for more information about your prescription drug coverage.
  • Ask about specific requirements for Farxiga, such as prior authorization or whether it's included in the formulary.
  • Inquire about any potential alternatives covered if Farxiga is not directly covered.

 

Follow the Prior Authorization Process

 

  • If Farxiga requires prior authorization, work with your healthcare provider to submit the necessary forms to Harvard Pilgrim.
  • Ensure the submission includes detailed information on why Farxiga is necessary for your treatment.
  • Be prepared to provide additional information if requested by Harvard Pilgrim during the review process.

 

Explore Appeals Process if Necessary

 

  • If your request for coverage is denied, review the denial letter from Harvard Pilgrim for details on the appeals process.
  • Compile documentation supporting the medical necessity of Farxiga, including healthcare provider letters and medical records.
  • Submit an appeal according to Harvard Pilgrim's specified procedures, ensuring all deadlines are met.

 

Explore Assistance Programs

 

  • If coverage challenges persist, consider exploring manufacturer assistance programs for Farxiga.
  • Contact the manufacturer directly or through your healthcare provider to inquire about patient assistance programs or discount cards.

 

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Farxiga FAQ

What are the side effects of Farxiga?

 

Common Side Effects of Farxiga

 

  • Increased urination due to its diuretic effect, which may lead to dehydration. Maintain adequate hydration.
  • Potential urinary tract infections or yeast infections in genital areas, due to changes in the urinary environment.

 

Metabolic Effects

 

  • Weight loss can occur, linked to its mechanism of expelling glucose via urine.
  • Electrolyte imbalances, such as elevated potassium levels in blood, may appear in some cases.

 

Serious Reactions

 

  • Ketoacidosis risk: Watch for symptoms like nausea, vomiting, or abdominal pain.
  • Rarely, serious infections like Fournier's gangrene can develop. Seek immediate attention if you notice pain, redness, or swelling in genital or anal areas.

 

Can Farxiga help with weight loss?

 

Can Farxiga Aid Weight Loss?

 

  • Farxiga (dapagliflozin) is primarily a medication for managing type 2 diabetes and heart failure. It helps control blood sugar by promoting the excretion of glucose through urine.

    •  

  • Though not prescribed primarily for weight loss, some patients experience weight reduction as a secondary benefit.

    •  

  • Weight loss occurs because Farxiga facilitates the removal of excess calories in the form of glucose. However, the effect is usually modest and not guaranteed for everyone.

    •  

  • Consult a healthcare professional to understand if Farxiga is suitable for your condition and weight management goals.

 

Is Farxiga used for heart failure treatment?

 

Farxiga for Heart Failure

 

  • Farxiga (dapagliflozin) is primarily a SGLT2 inhibitor, initially developed to treat type 2 diabetes by helping the kidneys excrete glucose.

    •  

  • Recent studies have shown Farxiga's efficacy in heart failure management, particularly heart failure with reduced ejection fraction (HFrEF), by reducing hospitalizations and improving cardiovascular outcomes.

    •  

  • The medication works by decreasing fluid overload and blood pressure, lessening the heart's workload.

    •  

  • Farxiga is approved for heart failure treatment regardless of diabetes status, broadening its use in cardiology.

    •  

Have questions left?

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

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