Does Harvard Pilgrim Health Care Cover Liraglutide (Saxenda)

Discover if Harvard Pilgrim covers Liraglutide (Saxenda) and learn steps to secure coverage and costs involved without insurance.
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Harvard Pilgrim Health Care Coverage for Liraglutide (Saxenda)

 

  • Coverage for Liraglutide (Saxenda) typically requires prior authorization, meaning the patient’s healthcare provider must verify that the medication is medically necessary.
  •  

  • The patient generally needs to meet specific criteria, such as having a clinical diagnosis of obesity with a BMI ≥ 30 or a BMI ≥ 27 with associated comorbidities like hypertension, type 2 diabetes, or dyslipidemia.
  •  

  • Patients must demonstrate previous attempts at weight management with lifestyle interventions and/or other weight loss medications without desired results.
  •  

  • Continuous coverage may require documentation of the effectiveness of Saxenda therapy, such as a clinically significant reduction in weight over a specified period.
  •  

  • Harvard Pilgrim may include exclusions such as not covering Saxenda for cosmetic weight loss purposes or use outside FDA-approved indications.

 

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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 Liraglutide (Saxenda) Coverage with Harvard Pilgrim Health Care

 

Verify Your Plan and Coverage

 

  • Check your specific Harvard Pilgrim Health Care plan to determine if Liraglutide (Saxenda) is covered. Coverage can vary based on your plan type and tier.
  • Review your plan's formulary, which lists covered medications. This can usually be found on the health insurance provider’s website or by contacting member services.

 

Consult with Your Healthcare Provider

 

  • Schedule a consultation with your healthcare provider to discuss your need for Liraglutide (Saxenda) and obtain a prescription. Your provider can offer guidance and justification for its necessity.
  • Ensure your healthcare provider provides any necessary documentation or medical history to support your treatment plan, which may be required for insurance approval.

 

Authorization and Exceptions

 

  • Determine if prior authorization is needed for Liraglutide (Saxenda) under your plan. Most plans require this for specialty medications to ensure they are used appropriately.
  • Work with your healthcare provider to complete any prior authorization forms. This may involve providing a detailed treatment history or justification letter.
  • If Liraglutide (Saxenda) is not listed in the formulary, inquire about the process for filing an exception request, which involves providing evidence of medical necessity.

 

Submit Required Documentation

 

  • Submit any required forms and documentation to Harvard Pilgrim Health Care as instructed. Keep copies of all submissions for your records.
  • Monitor the status of your submission through the healthcare provider’s member portal or by contacting customer service.

 

Appeal if Necessary

 

  • If coverage is denied, review the denial letter to understand the reasons. You have the right to appeal the decision.
  • Work with your healthcare provider to gather additional information and provide a stronger case for coverage during the appeal process.
  • Submit the appeal within the timeframe specified in the denial letter and follow up as needed to ensure your request is being reviewed.

 

Explore Support Programs

 

  • Investigate pharmaceutical assistance programs that may offer financial support or reduced pricing for Liraglutide (Saxenda).
  • Consider reaching out to the drug manufacturer, who may have programs available for patients experiencing insurance coverage issues.

 

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FAQs

Does Harvard Pilgrim Health Care Cover Liraglutide (Saxenda)

Discover if Harvard Pilgrim covers Liraglutide (Saxenda) and learn steps to secure coverage and costs involved without insurance.
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Is Liraglutide (Saxenda) Covered by Harvard Pilgrim Health Care

 

Harvard Pilgrim Health Care Coverage for Liraglutide (Saxenda)

 

  • Coverage for Liraglutide (Saxenda) typically requires prior authorization, meaning the patient’s healthcare provider must verify that the medication is medically necessary.
  •  

  • The patient generally needs to meet specific criteria, such as having a clinical diagnosis of obesity with a BMI ≥ 30 or a BMI ≥ 27 with associated comorbidities like hypertension, type 2 diabetes, or dyslipidemia.
  •  

  • Patients must demonstrate previous attempts at weight management with lifestyle interventions and/or other weight loss medications without desired results.
  •  

  • Continuous coverage may require documentation of the effectiveness of Saxenda therapy, such as a clinically significant reduction in weight over a specified period.
  •  

  • Harvard Pilgrim may include exclusions such as not covering Saxenda for cosmetic weight loss purposes or use outside FDA-approved indications.

 

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Harvard Pilgrim Health Care's Approved Criteria for Liraglutide (Saxenda) Coverage

 

Eligibility Criteria for Liraglutide (Saxenda) Coverage

 

  • **Body Mass Index (BMI):** The patient must have a BMI of 30 kg/m² or greater. If the patient has a BMI of 27 kg/m² to 29.9 kg/m², there must be a co-morbidity associated with obesity such as type 2 diabetes, hypertension, or dyslipidemia.
  •  

  • **Age Requirement:** The patient must be 18 years of age or older.
  •  

  • **Failure of Previous Weight Management:** The patient must have tried and failed to achieve a clinically meaningful weight loss or sustained weight loss with a structured weight loss program including a reduced calorie diet and increased physical activity.
  •  

  • **Medical Supervision:** Initiation and continuation of liraglutide should be prescribed and supervised by a healthcare provider experienced in managing patients with obesity.
  •  

  • **Regular Monitoring:** The treatment must include ongoing monitoring and lifestyle modifications as part of the overall obesity management plan.
  •  

  • **Initial Coverage Duration and Response Evaluation:** An initial coverage period will be provided (typically 16 weeks), after which the patient must demonstrate at least a 4% reduction in baseline body weight to continue the treatment.
  •  

 

Renewal Criteria for Continued Coverage

 

  • **Continued Weight Loss:** The patient should have continued positive response to treatment, showing evidence of further weight reduction or maintenance of initial weight loss.
  •  

  • **Adherence to Lifestyle Modifications:** The patient must continue adherence to a diet and exercise program under medical supervision.
  •  

  • **Absence of Adverse Effects:** The patient should not experience significant adverse effects that cannot be managed or are not outweighed by the benefits of treatment.
  •  

  • **Healthcare Provider Assessment:** A healthcare provider must reassess the benefit-risk of continuing Saxenda treatment as part of an ongoing comprehensive weight management program.
  •  

 

Why Harvard Pilgrim Health Care Might Deny Liraglutide (Saxenda) Coverage

 

Situations Where Harvard Pilgrim Health Care Might Deny Liraglutide (Saxenda) Coverage

 

  • Prescription of Liraglutide (Saxenda) for weight management does not meet the required clinical criteria established by the health plan.
  •  

  • The patient's body mass index (BMI) does not fall within the specified range necessary for drug approval according to plan guidelines.
  •  

  • Liraglutide (Saxenda) is prescribed for an individual with contraindications for this medication, such as a history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2.
  •  

  • The patient does not have any documented history of previous weight management efforts, such as lifestyle interventions, which is often required prior to the initiation of pharmacotherapy.
  •  

  • Authorization requests lack necessary documentation such as current BMI, laboratory results, or previous supportive treatments that justify the need for Liraglutide (Saxenda).
  •  

  • The prescribed dosage of Liraglutide (Saxenda) exceeds the maximum recommended dose or is not consistent with approved guidelines.
  •  

  • Request for coverage arises from a non-formulary status of the drug, whereby it is excluded from the health plan's list of covered medications based on formulary decisions.

 

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How Much Does Liraglutide (Saxenda) Cost without Insurance?

 

Liraglutide (Saxenda) Cost without Insurance

 

  • The cost of Liraglutide, commonly marketed under the brand name Saxenda, can vary based on location and pharmacy, but it typically ranges between $1,300 and $1,500 for a 30-day supply, which includes five injectable pens.
  •  

  • Prices can fluctuate due to factors like pharmacy pricing policies, manufacturer offers, and location. It is advisable to compare prices from various pharmacies or online sources.
  •  

  • Pharmacies may offer discount programs or coupons that could reduce the out-of-pocket cost. It's a good idea to inquire about available savings options.
  •  

  • Some online pharmacy platforms may provide competitive pricing and discounts, so checking these can be beneficial for finding better deals.
  •  

  • Prescription assistance programs, sometimes offered by the manufacturer, can provide help for individuals who meet certain income or insurance criteria. Exploring these options might also lead to cost savings.

 

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 Liraglutide (Saxenda) Coverage with Harvard Pilgrim Health Care

 

Verify Your Plan and Coverage

 

  • Check your specific Harvard Pilgrim Health Care plan to determine if Liraglutide (Saxenda) is covered. Coverage can vary based on your plan type and tier.
  • Review your plan's formulary, which lists covered medications. This can usually be found on the health insurance provider’s website or by contacting member services.

 

Consult with Your Healthcare Provider

 

  • Schedule a consultation with your healthcare provider to discuss your need for Liraglutide (Saxenda) and obtain a prescription. Your provider can offer guidance and justification for its necessity.
  • Ensure your healthcare provider provides any necessary documentation or medical history to support your treatment plan, which may be required for insurance approval.

 

Authorization and Exceptions

 

  • Determine if prior authorization is needed for Liraglutide (Saxenda) under your plan. Most plans require this for specialty medications to ensure they are used appropriately.
  • Work with your healthcare provider to complete any prior authorization forms. This may involve providing a detailed treatment history or justification letter.
  • If Liraglutide (Saxenda) is not listed in the formulary, inquire about the process for filing an exception request, which involves providing evidence of medical necessity.

 

Submit Required Documentation

 

  • Submit any required forms and documentation to Harvard Pilgrim Health Care as instructed. Keep copies of all submissions for your records.
  • Monitor the status of your submission through the healthcare provider’s member portal or by contacting customer service.

 

Appeal if Necessary

 

  • If coverage is denied, review the denial letter to understand the reasons. You have the right to appeal the decision.
  • Work with your healthcare provider to gather additional information and provide a stronger case for coverage during the appeal process.
  • Submit the appeal within the timeframe specified in the denial letter and follow up as needed to ensure your request is being reviewed.

 

Explore Support Programs

 

  • Investigate pharmaceutical assistance programs that may offer financial support or reduced pricing for Liraglutide (Saxenda).
  • Consider reaching out to the drug manufacturer, who may have programs available for patients experiencing insurance coverage issues.

 

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Our weight loss medication is delivered straight to your doorstep from a state-licensed pharmacy within our reliable network, ensuring you receive your medication when you need it.

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Liraglutide (Saxenda) FAQ

How much weight can you lose with Saxenda?

 

Weight Loss with Saxenda

 

  • Clinical trials show Saxenda users can lose an average of 5-10% of their initial body weight over 56 weeks.
  •  

  • Weight loss can vary depending on factors such as initial weight, diet, and physical activity.
  •  

  • Combining Saxenda with a reduced-calorie diet and increased physical activity enhances results.
  •  

  • It's important to monitor progress and consult with a healthcare provider to tailor the plan to individual needs.
  •  

  • Results are not guaranteed, and lifestyle changes significantly influence effectiveness.

What are the side effects of Liraglutide?

 

Common Side Effects

 

  • Nausea, particularly when starting treatment.
  • Vomiting or diarrhea, which can lead to dehydration.
  • Reduced appetite, a desired effect for weight management.
  • Headaches and dizziness, usually mild to moderate.

 

Serious Side Effects

 

  • Severe abdominal pain, signaling possible pancreatitis.
  • Symptoms of thyroid tumors, such as neck swelling or difficulty swallowing.
  • Serious allergic reactions, including hives or breath difficulty.
  • Elevated heart rate or palpitations.

 

Recommendations

 

  • Alert healthcare providers about any side effects.
  • Hydrate well to minimize dehydration from gastrointestinal effects.
  • Monitor blood sugar if diabetic, as levels may change.

 

How does Saxenda work for weight loss?

 

Mechanism of Action

 

  • Saxenda (liraglutide) is a GLP-1 receptor agonist. It mimics the action of the glucagon-like peptide-1, a hormone involved in appetite regulation.
  •  

  • It enhances insulin secretion and delays gastric emptying, promoting a feeling of fullness.

 

Appetite Suppression

 

  • Saxenda targets areas of the brain that control hunger, reducing appetite and calorie intake.
  •  

  • This helps in forming healthier eating habits and better portion control.

 

Additional Benefits

 

  • Besides weight loss, it assists in improving glycemic control for type 2 diabetes patients.
  •  

  • May lead to reductions in waist circumference and improvements in cardiovascular measures.

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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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