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Does Harvard Pilgrim Health Care Cover Xarelto

Explore if Harvard Pilgrim Health Care covers Xarelto, reasons for denial, ways to secure coverage, costs without insurance, and find answers to common questions.
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Harvard Pilgrim Coverage for Xarelto

 

  • Harvard Pilgrim Health Care typically covers Xarelto, a medication used to treat and prevent blood clots in specific medical conditions.

    •  

  • Coverage may depend on the plan type and patient’s medical necessity as determined by their healthcare provider. Prior authorization may be required.

    •  

  • The medication is often covered for individuals with conditions such as deep vein thrombosis, pulmonary embolism, or to reduce the risk of stroke in people with atrial fibrillation not caused by a heart valve issue.

    •  

  • Patients must generally meet specific criteria outlined in the plan’s formulary guidelines, and coverage might involve copayments, co-insurance, or meeting a deductible.

    •  

  • For precise details on coverage, costs, and requirements, it is best to consult the specific policy documents or contact Harvard Pilgrim’s member services.

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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 Xarelto Coverage with Harvard Pilgrim Health Care

 

Check Your Current Health Plan

 

  • Review your existing Harvard Pilgrim Health Care policy documents for information on prescription drug coverage.
    •  
  • Log into your Harvard Pilgrim member account online to access detailed benefits information, including specific medications covered.

 

Consult the Harvard Pilgrim Formulary

 

  • Access the Harvard Pilgrim drug formulary through their official website or contact customer service for the latest version. This document outlines which medications are covered and at what level.
    •  
  • Search for Xarelto within the formulary to verify its coverage status and determine any specific coverage tiers or requirements.

 

Contact Customer Service

 

  • Call Harvard Pilgrim customer service using the number on your member ID card for assistance regarding your prescription coverage options.
    •  
  • Ask about prerequisites for Xarelto coverage, such as prior authorization or step therapy requirements.

 

Consult with Your Healthcare Provider

 

  • Discuss your prescription needs with your doctor, ensuring that Xarelto is the recommended medication for your condition.
    •  
  • Have your doctor provide any necessary documentation or medical justification if Harvard Pilgrim requires prior authorization for Xarelto.

 

Submit a Prior Authorization Request

 

  • If prior authorization is needed, work with your healthcare provider to complete and submit the necessary forms to Harvard Pilgrim.
    •  
  • Ensure all relevant medical information is included to facilitate a smooth approval process.

 

Explore Financial Assistance Options

 

  • If cost is a concern, check if you qualify for patient assistance programs or pharmaceutical discounts for Xarelto.
    •  
  • Explore any financial assistance programs offered through Harvard Pilgrim or external organizations.
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Does Harvard Pilgrim Health Care Cover Xarelto

Explore if Harvard Pilgrim Health Care covers Xarelto, reasons for denial, ways to secure coverage, costs without insurance, and find answers to common questions.
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Is Xarelto Covered by Harvard Pilgrim Health Care

 

Harvard Pilgrim Coverage for Xarelto

 

  • Harvard Pilgrim Health Care typically covers Xarelto, a medication used to treat and prevent blood clots in specific medical conditions.

    •  

  • Coverage may depend on the plan type and patient’s medical necessity as determined by their healthcare provider. Prior authorization may be required.

    •  

  • The medication is often covered for individuals with conditions such as deep vein thrombosis, pulmonary embolism, or to reduce the risk of stroke in people with atrial fibrillation not caused by a heart valve issue.

    •  

  • Patients must generally meet specific criteria outlined in the plan’s formulary guidelines, and coverage might involve copayments, co-insurance, or meeting a deductible.

    •  

  • For precise details on coverage, costs, and requirements, it is best to consult the specific policy documents or contact Harvard Pilgrim’s member services.

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Harvard Pilgrim Health Care's Approved Criteria for Xarelto Coverage

 

Harvard Pilgrim Xarelto Coverage Criteria

 

  • **Approved Diagnosis**: Coverage is provided if Xarelto is prescribed for medically necessary conditions approved by Harvard Pilgrim, such as non-valvular atrial fibrillation, deep vein thrombosis (DVT), pulmonary embolism (PE), and for reduction of risk of recurrence of DVT and PE.

    •  

  • **Prescriber Qualification**: The prescription must be written by a qualified health professional, either a cardiologist, hematologist, or other relevant specialists.

    •  

  • **Age Restriction**: Patients must meet specific age requirements based on their condition. Coverage may require patients to be within a certain age range, typically adults aged 18 and older, unless otherwise specified.

    •  

  • **Other Medications**: Patients must have a documented history of failure, contraindication, or intolerance to alternative anticoagulant therapies, or must be prescribed Xarelto for a condition where it is considered first-line treatment.

    •  

  • **Dosage and Administration**: The prescription must align with FDA-approved dosing guidelines and indications for the condition being treated.

    •  

  • **Compliance with Guidelines**: Coverage is contingent on the medication being used in accordance with evidence-based clinical guidelines and standards, emphasizing the appropriateness for the specific condition.

    •  

  • **Duration of Treatment**: Depending on the diagnosis, approval may include specific limitations on the duration of treatment with periodic reassessment to justify continued use.

 

Important Considerations

 

  • **Prior Authorization**: Some conditions may require prior authorization from Harvard Pilgrim to ensure necessity and compliance with their guidelines.

    •  

  • **Reevaluation**: Continuous treatment may need periodic evaluation by a healthcare provider to ensure the ongoing need and effectiveness of the medication.

    •  

  • **Documentation**: Providers must submit thorough clinical documentation that supports the medical necessity and adheres to Harvard Pilgrim's established clinical guidelines.

 

Why Harvard Pilgrim Health Care Might Deny Xarelto Coverage

 

Xarelto Coverage Denial Criteria

 

  • **Usage Not According to Indication:** Xarelto may be denied if it is prescribed for a condition that is not FDA-approved or not covered under the plan’s policy. Off-label uses are typically not covered.

    •  

  • **Lack of Prior Authorization:** Coverage could be denied if the necessary prior authorization process was not completed or approved before the prescription was filled.

    •  

  • **Failure to Meet Step Therapy Requirements:** If alternative, less expensive medications must be tried and failed before Xarelto can be covered, not following this protocol may result in denial.

    •  

  • **Non-Participation in Required Programs:** If the patient is not willing or does not complete participation in required clinical programs that ensure appropriate use, coverage might be denied.

    •  

  • **Inadequate Documentation:** If the insurer deems that the necessary medical documentation to support the need for Xarelto is insufficient or incomplete, the claim may be rejected.

    •  

  • **Duplicate Therapy Concerns:** Denial can occur if there is evidence of prescription overlap indicating duplicate therapy with similar anticoagulants.

    •  

  • **Non-Compliance with Prescribing Guidelines:** Claims may be denied if the prescribing physician does not adhere to specific dosing guidelines or other clinical guidelines stipulated by the health plan.

    •  

  • **Plan Exclusion Policies:** If the health plan specifically excludes Xarelto under certain conditions or categories, these exclusions will lead to coverage denial.

    •  

  • **Unresolved Coverage Gaps:** If there are gaps in coverage history or unresolved issues related to eligibility, these can result in non-coverage.

 

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How Much Does Xarelto Cost without Insurance?

 

Approximate Cost of Xarelto Without Insurance

 

  • The cost for Xarelto, a prescription anticoagulant medication, can vary depending on the dosage and quantity prescribed. On average, the cost of a 30-day supply of Xarelto 20 mg tablets, without insurance, can range from $450 to $540.

    •  

  • Prices may differ at various pharmacies, and patients might find lower prices through discount programs or pharmacy discount cards.

    •  

  • Shopping around and comparing prices at different pharmacies or checking with online retailers can sometimes yield better deals or discounts.

    •  

  • Additional savings may be available through pharmaceutical assistance programs, which are offered by the manufacturer for eligible patients who meet specific criteria.

 

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 Xarelto Coverage with Harvard Pilgrim Health Care

 

Check Your Current Health Plan

 

  • Review your existing Harvard Pilgrim Health Care policy documents for information on prescription drug coverage.
    •  
  • Log into your Harvard Pilgrim member account online to access detailed benefits information, including specific medications covered.

 

Consult the Harvard Pilgrim Formulary

 

  • Access the Harvard Pilgrim drug formulary through their official website or contact customer service for the latest version. This document outlines which medications are covered and at what level.
    •  
  • Search for Xarelto within the formulary to verify its coverage status and determine any specific coverage tiers or requirements.

 

Contact Customer Service

 

  • Call Harvard Pilgrim customer service using the number on your member ID card for assistance regarding your prescription coverage options.
    •  
  • Ask about prerequisites for Xarelto coverage, such as prior authorization or step therapy requirements.

 

Consult with Your Healthcare Provider

 

  • Discuss your prescription needs with your doctor, ensuring that Xarelto is the recommended medication for your condition.
    •  
  • Have your doctor provide any necessary documentation or medical justification if Harvard Pilgrim requires prior authorization for Xarelto.

 

Submit a Prior Authorization Request

 

  • If prior authorization is needed, work with your healthcare provider to complete and submit the necessary forms to Harvard Pilgrim.
    •  
  • Ensure all relevant medical information is included to facilitate a smooth approval process.

 

Explore Financial Assistance Options

 

  • If cost is a concern, check if you qualify for patient assistance programs or pharmaceutical discounts for Xarelto.
    •  
  • Explore any financial assistance programs offered through Harvard Pilgrim or external organizations.

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Xarelto FAQ

What are the common side effects of Xarelto?

 

Common Side Effects of Xarelto

 

  • Bleeding is the most common, including nasal, gum, or gastrointestinal bleeding. Be vigilant for any signs of unusual bleeding and seek medical attention if necessary.

    •  

  • Gastrointestinal issues such as nausea and stomach pain may occur. Taking Xarelto with food can help alleviate these symptoms.

    •  

  • Dizziness and fatigue can affect some individuals, especially when first starting the medication. Ensure you maintain hydration and rest as needed.

    •  

  • In rare cases, allergic reactions may manifest as rash or itching. If this occurs, consult your healthcare provider promptly.

 

Is Xarelto a blood thinner?

 

Is Xarelto a Blood Thinner?

 

  • **Xarelto (rivaroxaban)** is indeed a blood thinner, specifically an anticoagulant, which is crucial for preventing blood clots that can lead to conditions like stroke or deep vein thrombosis (DVT).

    •  

  • It works by inhibiting **factor Xa**, an essential component in the coagulation cascade, reducing the ability of blood to form clots.

    •  

  • As a **direct oral anticoagulant (DOAC)**, it provides several advantages over traditional blood thinners like warfarin, such as having fewer dietary restrictions and not requiring regular blood monitoring.

    •  

  • It's important to take it as prescribed by a healthcare provider, considering potential drug interactions and contraindications.

 

Can you drink alcohol while taking Xarelto?

 

Drinking Alcohol with Xarelto

 

  • Xarelto, a blood thinner, may increase bleeding risk, and alcohol can amplify this risk.

    •  

  • Both substances affect liver function, potentially impacting medication metabolism and effectiveness.

    •  

  • Consuming alcohol while on Xarelto may enhance side effects like dizziness, increasing injury risk.

    •  

  • It’s crucial to consult your healthcare provider to discuss allowable alcohol intake based on your health status and dosage.

    •  

 

General Recommendations

 

  • Moderation is key – if approved, limit alcohol consumption as per medical advice.

    •  

  • Avoid binge drinking, which drastically heightens risk of adverse reactions.

    •  

  • Inform your medical team about recreational activities involving alcohol.

 

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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Curex-affiliated medical practices are independently owned and operated by licensed physicians who provide services using the Curex telehealth platform.

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