Does Harvard Pilgrim Health Care Cover Saxenda

Uncover if Harvard Pilgrim Health Care covers Saxenda, understand coverage denial reasons, learn steps to secure coverage, and explore Saxenda costs.
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Harvard Pilgrim Health Care Coverage for Saxenda

 

  • Saxenda, a weight management medication, may be covered by Harvard Pilgrim Health Care under specific circumstances. It's intended for individuals with obesity or weight-related comorbidities such as type 2 diabetes, hypertension, or high cholesterol.
  •  

  • To qualify for coverage, patients often need to demonstrate a clinical necessity, which typically involves a documented history of failed weight loss with lifestyle changes alone.
  •  

  • A prescription from a healthcare provider is crucial, along with prior authorization that supports Saxenda as a medically necessary treatment.
  •  

  • Harvard Pilgrim may have specific formulary requirements or tiered prescription plans affecting copays and coverage decisions.
  •  

  • Patients are encouraged to consult directly with Harvard Pilgrim Health Care or their healthcare provider to fully understand the specific criteria and documentation required for Saxenda coverage.

 

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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 Saxenda Coverage with Harvard Pilgrim Health Care

 

Confirm Saxenda Coverage

 

  • Contact Harvard Pilgrim Health Care directly through customer service to inquire about Saxenda coverage.
  •  

  • Check the insurance policy documents or online member portal for specific information regarding prescription drug benefits related to weight management medications.

 

Consult with Healthcare Provider

 

  • Schedule a consultation with your healthcare provider to discuss Saxenda as a treatment option and confirm its necessity for your condition.
  •  

  • Ensure your provider understands you have Harvard Pilgrim Health Care, as they may need to provide specific documentation or justification to facilitate coverage.

 

Obtain Prior Authorization

 

  • Ask your healthcare provider to submit a prior authorization request to Harvard Pilgrim Health Care. This is often required for coverage of medications like Saxenda.
  •  

  • Make sure the prior authorization request includes all necessary medical documentation and justification for using Saxenda, such as BMI information and any previous weight management efforts.

 

Submit Prescription

 

  • Once prior authorization is approved, have your healthcare provider send the prescription for Saxenda to your preferred pharmacy.
  •  

  • Confirm with the pharmacy that they have received the prescription and have verified it with Harvard Pilgrim Health Care.

 

Follow-Up with Insurance

 

  • After submitting the prescription, monitor your insurance claims through Harvard Pilgrim's member portal or contact customer service to ensure Saxenda is being processed and covered properly.
  •  

  • If there are any issues or denials, work with your healthcare provider to provide additional documentation or appeal the decision if necessary.

 

Utilize Member Resources

 

  • Take advantage of any additional resources or support programs offered by Harvard Pilgrim Health Care related to medication management or weight loss.
  •  

  • Consider enrolling in any available wellness programs or consultations that may complement your Saxenda treatment.

 

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FAQs

Does Harvard Pilgrim Health Care Cover Saxenda

Uncover if Harvard Pilgrim Health Care covers Saxenda, understand coverage denial reasons, learn steps to secure coverage, and explore Saxenda costs.
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Is Saxenda Covered by Harvard Pilgrim Health Care

 

Harvard Pilgrim Health Care Coverage for Saxenda

 

  • Saxenda, a weight management medication, may be covered by Harvard Pilgrim Health Care under specific circumstances. It's intended for individuals with obesity or weight-related comorbidities such as type 2 diabetes, hypertension, or high cholesterol.
  •  

  • To qualify for coverage, patients often need to demonstrate a clinical necessity, which typically involves a documented history of failed weight loss with lifestyle changes alone.
  •  

  • A prescription from a healthcare provider is crucial, along with prior authorization that supports Saxenda as a medically necessary treatment.
  •  

  • Harvard Pilgrim may have specific formulary requirements or tiered prescription plans affecting copays and coverage decisions.
  •  

  • Patients are encouraged to consult directly with Harvard Pilgrim Health Care or their healthcare provider to fully understand the specific criteria and documentation required for Saxenda coverage.

 

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Harvard Pilgrim Health Care's Approved Criteria for Saxenda Coverage

 

Criteria for Saxenda Coverage

 

  • Beneficiary must have a documented Body Mass Index (BMI) of 30 kg/m2 or higher, indicating obesity, or a BMI of 27 kg/m2 or higher with at least one weight-related comorbidity such as hypertension, type 2 diabetes mellitus, or dyslipidemia.
  •  

  • The member should have attempted lifestyle modifications that include a structured diet and exercise program for at least 6 months prior, without satisfactory weight loss.
  •  

  • Saxenda should be prescribed by or received consultation with a healthcare professional specializing in obesity management, endocrinology, or a similar field.
  •  

  • There should be evidence of a combination therapy plan that includes continued lifestyle intervention such as ongoing diet and exercise management along with Saxenda therapy.
  •  

  • Initial approval for Saxenda is typically granted for a 3-month trial period, during which a documented weight reduction of at least 4% of baseline body weight must be achieved to qualify for continued treatment.
  •  

  • The prescriber is required to submit medical records or documentation validating the patient’s weight loss progress and adherence to treatment and lifestyle interventions every 6 months for continual coverage.
  •  

  • Harvard Pilgrim covers Saxenda for patients meeting these criteria based on FDA-approved indications and dosing recommendations.

Why Harvard Pilgrim Health Care Might Deny Saxenda Coverage

 

Reasons for Coverage Denial

 

  • Saxenda is not covered if it is being prescribed for non-FDA approved uses, such as weight management in patients who do not meet the specific criteria for obesity-related indications.
  •  

  • Harvard Pilgrim Health Care may deny coverage if the patient does not meet the Body Mass Index (BMI) criteria, typically a BMI of 30 kg/m² or higher, or a BMI of 27 kg/m² with weight-related comorbidities.
  •  

  • Patients who have not tried or completed a comprehensive lifestyle intervention program, including both diet and exercise, may be denied coverage for Saxenda.
  •  

  • If Saxenda is prescribed for cosmetic weight loss purposes or short-term weight management, it will not be covered by Harvard Pilgrim Health Care.
  •  

  • Saxenda coverage might be rejected if prior authorization requirements are not met, such as documentation of earlier weight loss attempts or failure to achieve weight loss with other medications.
  •  

  • Harvard Pilgrim Health Care may deny coverage if there is a lack of documentation supporting medical necessity as defined by the health plan's policy criteria.

 

Exclusion Due to Pre-existing Medical Conditions

 

  • Coverage might be denied if the patient has a history of medullary thyroid carcinoma (MTC) or if there is a known family history of this cancer.
  •  

  • Individuals with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2) are typically not eligible for Saxenda coverage according to Harvard Pilgrim Health Care policies.

 

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How Much Does Saxenda Cost without Insurance?

 

Approximate Cost of Saxenda Without Insurance

 

  • Saxenda is a prescription medication used to aid in weight loss and management for patients who are overweight or have obesity-related medical problems.
  •  

  • Without insurance, the cost of Saxenda can be substantial. Prices typically range from $1,200 to $1,500 for a 30-day supply, which consists of 3 pens.
  •  

  • The exact cost can vary based on the pharmacy you visit and potential discounts or coupons you may be able to use.
  •  

  • It's important to consider the long-term cost if Saxenda is prescribed for an extended period, as the monthly expense can add up significantly over time.
  •  

  • Some pharmacies may offer loyalty programs or discounts that can slightly reduce the cost, so it's advisable to shop around or inquire about savings programs.
  •  

  • Additionally, pharmaceutical assistance programs or patient assistance programs might be available for eligible patients to help minimize out-of-pocket costs.

 

Our team is here to help!

Dr. Neeta Ogden, MD

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

Dr. Ravi Patel, VP Telemedicine

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

Jill Hamburg, PA - C

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

Dr. Chet Tharpe, Medical Director

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

Kayla Mardaga, NP

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

How to Get Saxenda Coverage with Harvard Pilgrim Health Care

 

Confirm Saxenda Coverage

 

  • Contact Harvard Pilgrim Health Care directly through customer service to inquire about Saxenda coverage.
  •  

  • Check the insurance policy documents or online member portal for specific information regarding prescription drug benefits related to weight management medications.

 

Consult with Healthcare Provider

 

  • Schedule a consultation with your healthcare provider to discuss Saxenda as a treatment option and confirm its necessity for your condition.
  •  

  • Ensure your provider understands you have Harvard Pilgrim Health Care, as they may need to provide specific documentation or justification to facilitate coverage.

 

Obtain Prior Authorization

 

  • Ask your healthcare provider to submit a prior authorization request to Harvard Pilgrim Health Care. This is often required for coverage of medications like Saxenda.
  •  

  • Make sure the prior authorization request includes all necessary medical documentation and justification for using Saxenda, such as BMI information and any previous weight management efforts.

 

Submit Prescription

 

  • Once prior authorization is approved, have your healthcare provider send the prescription for Saxenda to your preferred pharmacy.
  •  

  • Confirm with the pharmacy that they have received the prescription and have verified it with Harvard Pilgrim Health Care.

 

Follow-Up with Insurance

 

  • After submitting the prescription, monitor your insurance claims through Harvard Pilgrim's member portal or contact customer service to ensure Saxenda is being processed and covered properly.
  •  

  • If there are any issues or denials, work with your healthcare provider to provide additional documentation or appeal the decision if necessary.

 

Utilize Member Resources

 

  • Take advantage of any additional resources or support programs offered by Harvard Pilgrim Health Care related to medication management or weight loss.
  •  

  • Consider enrolling in any available wellness programs or consultations that may complement your Saxenda treatment.

 

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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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Saxenda FAQ

1. How much weight can you lose with Saxenda?

 

Expected Weight Loss with Saxenda

 

  • According to clinical studies, Saxenda helps achieve significant weight loss; patients can expect to lose around 5% to 10% of their initial body weight.
  •  

  • The average weight loss in clinical trials was approximately 8%, but individual results can vary based on several factors including diet and exercise.
  •  

  • For some, weight loss may exceed 10%, while others may experience less than 5% reduction.
  •  

  • Adopt lifestyle changes alongside Saxenda, like improved diet and increased physical activity, to maximize weight loss.
  •  

 

2. What are the common side effects of Saxenda?

 

Common Side Effects of Saxenda

 

  • Nausea: This is the most frequently reported side effect, often decreasing over time as the body adjusts.
  •  

  • Diarrhea: Changes in bowel habits, including diarrhea, are possible but usually manageable.
  •  

  • Constipation: Some patients experience constipation, a common gastrointestinal effect.
  •  

  • Vomiting: Vomiting can occur, especially in the initial stages of treatment.
  •  

  • Headache: Many patients report headaches, though these often lessen as treatment progresses.
  •  

  • Dizziness: Feeling lightheaded or dizzy can accompany Saxenda use.
  •  

  • Fatigue: Tiredness or fatigue is commonly noted but tends to be temporary.
  •  

  • Injection Site Reactions: Redness or irritation at the injection site may occur.

 

3. How long does it take for Saxenda to start working?

 

How Saxenda Works

 

  • Saxenda is a GLP-1 receptor agonist, which works by decreasing appetite and caloric intake.
  •  

  • The onset of its effects can vary among individuals.

 

Timeframe for Effects

 

  • Patients may start experiencing decreased appetite within the first week of treatment.
  •  

  • Noticeable weight loss usually begins after 4-8 weeks, especially when combined with a reduced-calorie diet and increased physical activity.

 

Monitoring Progress

 

  • Regular follow-ups with your healthcare provider are essential to assess progress and adjust the dosage if necessary.
  •  

  • Adherence to lifestyle changes significantly enhances results with Saxenda.

 

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We gradually adjust your dosage to reach the optimal therapeutic level, ensuring maximum effectiveness while minimizing potential side effects.

Additional Treatments

Our providers may also recommend medications such as metformin or supplements such as vitamin B12. We recognize the importance of managing side effects, so your care plan may include medication to alleviate them.

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Do your plans include prescriptions and medications?

Curex plans cover everything from reviewing your medical intake to providing prescription medications, with free shipping included. There are no extra or hidden charges. Prescriptions are issued only after a medical provider reviews your information to confirm that the medication is suitable for you. Our service includes continuous support and regular follow-ups to ensure your treatment stays on track.

Our clinicians may order labs and additional medications for you, which would not be covered by the plan but for which you can use your insurance.

Please note: Compounded medications are tailored to individual needs or used in case of shortages, but they are not FDA-approved for safety or effectiveness. A prescription is required. Results may vary from person to person.

What medications do your providers prescribe?

We prioritize a personalized approach to your health. If your medical provider prescribes medication, options may include GLP-1 treatments such as compounded semaglutide (the active ingredient in Wegovy®* and Ozempic®*). Our providers prescribe only combination treatments not available at your local pharmacy that may include vitamin B12, etc. to help you achieve your goals faster.

Depending on your treatment goals, other medications such as metformin may also be considered. We recognize the importance of managing side effects, so your care plan might include medication to ease symptoms like nausea. Your well-being is always our top priority!

Please note that compounded medications are customized to meet individual patient needs and are not FDA-approved for safety or effectiveness. A prescription is necessary. Results may vary from person to person.

Curex and its pharmacy partners do not have any association with Novo Nordisk.

Will I be prescribed semaglutide if I sign up?

Your health journey is unique, and we tailor our care to match. Any prescriptions, including semaglutide, will be based on the expert assessment of the medical provider matched with you through our platform. You can trust that your treatment plan will be personalized to fit your specific needs. And if semaglutide is not prescribed, we will provide a full refund.

What is compounded medication?

Compounding involves creating customized medications to meet the specific needs of individual patients. For instance, a patient may require a liquid version of a medication that is only available in tablet form. Pharmacies can also compound medications using FDA-approved drugs that are on the FDA’s shortage list.

These compounded medications are made by state-licensed pharmacies that follow both federal and state regulations, including quality standards. However, when compounded in accordance with these laws, these medications are not subject to FDA approval and are not evaluated for safety or effectiveness.

Is compounded medication the same as generic medication?

Compounded medications differ from generic drugs. Generics require FDA approval by demonstrating bio-equivalence to the brand-name drug. In contrast, compounded medications are not FDA-approved. They are made based on a personalized prescription that may not be commercially available elsewhere or when a drug appears on the FDA’s shortage list. Compounding pharmacies must have the proper licensed facilities and comply with state and federal regulations before dispensing these medications.

Is insurance required?

No, Curex doesn’t require insurance. We offer clear and simple pricing, along with affordable medication options, making it easy and accessible to take care of your health.

Can I pay with an FSA or HSA card?

Yes! You can pay with your HSA or FSA card.

How much does treatment cost?

Semaglutide Injections:

Prices for semaglutide start at only $149 per month for weekly doses of 0.25mg and 0.5mg. You can cancel anytime. Some people experience weight loss at these doses and higher doses aren't advisable due to a higher risk of side effects. If you need a higher dose to achieve your weight loss goals, we offer higher-dose plans for 1mg, 1.7mg and 2.4mg of semaglutide for an additional $50 per month for each plan.

Tirzepatide Injections:

Prices for tirzepatide start at only $249 per month for weekly doses of 2.5mg and 5mg of tirzepatide.You can cancel anytime. Some people experience weight loss at these doses and higher doses aren't advisable due to a higher risk of side effects. If you need a higher dose to achieve your weight loss goals, we offer higher-dose plans for 7.5mg, 10mg and 12.5mg of tirzepatide for an additional $100 per month for each plan.

Semaglutide Tablets:

Prices for semaglutide tablets start at only $149 per month for daily doses of 2mg. You can cancel anytime. Some people experience weight loss at this dose and higher doses aren't advisable due to a higher risk of side effects. If you need a higher dose to achieve your weight loss goals, we offer higher-dose plans for 4mg and 8mg of semaglutide daily for an additional $50 per month for each plan.

Tirzepatide Tablets:

Prices for tirzepatide start at only $199 per month for daily dosees of 3mg of tirzepatide. You can cancel anytime. Some people experience weight loss at these doses and higher doses aren't advisable due to a higher risk of side effects. If you need a higher dose to achieve your weight loss goals, we offer higher-dose plans for 6mg and 12 mg of tirzepatide daily for an additional $100 per month for each plan.

Can you prescribe Ozempic®* or Wegovy®*?

Our providers focus on personalized medications and dosages that aren’t commercially available at your local pharmacy. While we don’t prescribe Ozempic®* or Wegovy®* directly, we may prescribe treatments containing the same active ingredient. These medications are specially compounded for you by a licensed pharmacy to meet your specific needs.

Are video visits with a provider required?

Our providers will review your information 100% online. Depending on where you live and the specifics of your medical history, our providers may require you to have a video visit or asynchronous visit via text message. If prescribed, you’ll get unlimited online access to message your provider as needed for follow-ups, adjustments, and answers to your questions.

What states do you serve?

Currently, we do not serve Arkansas, Connecticut, and New Mexico. However, we are always working to expand our reach, so stay in touch with us at hi@getcurex.com.

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