Does Highmark Cover Liraglutide (Saxenda)

Explore Liraglutide (Saxenda) coverage with Highmark, strategies for approval, costs without insurance, and answers to FAQs in this comprehensive guide.
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Coverage Criteria for Liraglutide (Saxenda) by Highmark

 

  • Highmark may cover Liraglutide (Saxenda) based on medical necessity for weight management.
  •  

  • Candidates typically need to have a BMI of 30 or greater, or a BMI of 27 or greater with related conditions like hypertension or type 2 diabetes.
  •  

  • A comprehensive weight management program should be in place, including diet and exercise plans.
  •  

  • Documentation of previous unsuccessful weight loss attempts may be required.

 

Basic Requirements

 

  • A detailed physician's statement or prior authorization request is often necessary.
  •  

  • Certain policy plans may have specific formularies; beneficiaries should confirm with Highmark directly to ensure coverage.
  •  

  • Annual re-evaluation of treatment effectiveness might be needed to continue 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 Liraglutide (Saxenda) Coverage with Highmark

 

Understand Highmark Insurance Parameters

 

  • Contact Highmark customer service to obtain detailed information on their specific coverage criteria and requirements for Liraglutide (Saxenda).
  •  

  • Visit the Highmark website and log into your member portal to access documents related to pharmaceutical coverage and guidelines.

 

Consult with Your Healthcare Provider

 

  • Schedule a consultation with your healthcare provider to discuss your medical condition and the necessity of Liraglutide (Saxenda) as part of your treatment plan.
  •  

  • Request your healthcare provider to compose a medical necessity letter, detailing why Liraglutide (Saxenda) is essential for your treatment and how it aligns with Highmark's coverage criteria.

 

Submit Prior Authorization Request

 

  • Work with your healthcare provider to complete and submit a prior authorization form to Highmark. This is often mandatory for coverage of medications like Liraglutide (Saxenda).
  •  

  • Ensure all required documents, including the medical necessity letter and any other supporting evidence, are attached to the authorization request.

 

Follow Up on Authorization Status

 

  • Contact Highmark's authorization department to verify that your prior authorization request has been received and is in process.
  •  

  • Request a timeline for when you can expect a decision on your prior authorization request.

 

Appeal if Necessary

 

  • If your request is denied, review the denial letter carefully for the reason provided by Highmark. This usually includes important information on how to file an appeal.
  •  

  • Gather additional documentation and evidence with your healthcare provider to support your case, addressing the denial reasons directly.
  •  

  • Submit an appeal, following Highmark's specified procedure, and keep detailed records of all correspondence.

 

Explore Alternative Support Program

 

  • Investigate available patient assistance programs which might offer Liraglutide (Saxenda) at a reduced cost or through rebates, especially if repeated authorization attempts fail.
  •  

  • Discuss alternative medications or treatment strategies with your healthcare provider if cost remains an obstacle.

 

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FAQs

Does Highmark Cover Liraglutide (Saxenda)

Explore Liraglutide (Saxenda) coverage with Highmark, strategies for approval, costs without insurance, and answers to FAQs in this comprehensive guide.
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Is Liraglutide (Saxenda) Covered by Highmark

 

Coverage Criteria for Liraglutide (Saxenda) by Highmark

 

  • Highmark may cover Liraglutide (Saxenda) based on medical necessity for weight management.
  •  

  • Candidates typically need to have a BMI of 30 or greater, or a BMI of 27 or greater with related conditions like hypertension or type 2 diabetes.
  •  

  • A comprehensive weight management program should be in place, including diet and exercise plans.
  •  

  • Documentation of previous unsuccessful weight loss attempts may be required.

 

Basic Requirements

 

  • A detailed physician's statement or prior authorization request is often necessary.
  •  

  • Certain policy plans may have specific formularies; beneficiaries should confirm with Highmark directly to ensure coverage.
  •  

  • Annual re-evaluation of treatment effectiveness might be needed to continue coverage.

 

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Highmark's Approved Criteria for Liraglutide (Saxenda) Coverage

 

Criteria for Coverage of Liraglutide (Saxenda)

 

  • The patient must have a body mass index (BMI) greater than or equal to 30 kg/m², indicating obesity.
  •  

  • Alternatively, the patient may have a BMI greater than or equal to 27 kg/m² if there is a weight-related comorbidity such as hypertension, type 2 diabetes, or dyslipidemia.
  •  

  • The patient has attempted weight loss through a reduced-calorie diet and increased physical activity, and these efforts have failed to produce significant weight loss.
  •  

  • Liraglutide (Saxenda) should be prescribed as part of a comprehensive weight management program, which includes a reduced-calorie diet and increased physical activity.
  •  

  • The patient must be 18 years of age or older.
  •  

  • The prescribing physician should be an endocrinologist, or there should be documentation of consultation with a specialist in obesity management, where applicable.
  •  

  • Continued approval of Liraglutide (Saxenda) beyond the initial coverage is contingent on documentation of weight loss in the patient taking the medication, involving a reduction in body weight of at least 4% during the initial 16-week trial phase.
  •  

  • The patient must not be taking any other products intended for weight loss while receiving Liraglutide (Saxenda), to prevent drug interactions and adverse effects.

 

Why Highmark Might Deny Liraglutide (Saxenda) Coverage

 

Situations Where Highmark Might Deny Liraglutide (Saxenda) Coverage

 

  • Prescription without a prior authorization request that meets all established requirements.
  •  

  • Use outside of FDA-approved indications, such as for conditions other than chronic weight management.
  •  

  • Patient demographics or medical history do not meet Highmark's clinical criteria for obesity treatment, such as specific BMI thresholds or comorbid conditions.
  •  

  • Lack of documented trial and failure, or intolerance to, other weight-loss drugs specified in Highmark's policy criteria.
  •  

  • Attempting to use for concurrent weight management alongside other weight-loss medications not approved by Highmark.
  •  

  • Failure to provide necessary health records or information that supports the necessity of Saxenda as per Highmark's policy.
  •  

  • Noncompliance with Highmark's step therapy protocols, if applicable, requiring previous usage of alternative treatments.
  •  

  • Prescription for individuals under the age of 18, unless specified differently by policy updates from Highmark.

 

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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 Highmark

 

Understand Highmark Insurance Parameters

 

  • Contact Highmark customer service to obtain detailed information on their specific coverage criteria and requirements for Liraglutide (Saxenda).
  •  

  • Visit the Highmark website and log into your member portal to access documents related to pharmaceutical coverage and guidelines.

 

Consult with Your Healthcare Provider

 

  • Schedule a consultation with your healthcare provider to discuss your medical condition and the necessity of Liraglutide (Saxenda) as part of your treatment plan.
  •  

  • Request your healthcare provider to compose a medical necessity letter, detailing why Liraglutide (Saxenda) is essential for your treatment and how it aligns with Highmark's coverage criteria.

 

Submit Prior Authorization Request

 

  • Work with your healthcare provider to complete and submit a prior authorization form to Highmark. This is often mandatory for coverage of medications like Liraglutide (Saxenda).
  •  

  • Ensure all required documents, including the medical necessity letter and any other supporting evidence, are attached to the authorization request.

 

Follow Up on Authorization Status

 

  • Contact Highmark's authorization department to verify that your prior authorization request has been received and is in process.
  •  

  • Request a timeline for when you can expect a decision on your prior authorization request.

 

Appeal if Necessary

 

  • If your request is denied, review the denial letter carefully for the reason provided by Highmark. This usually includes important information on how to file an appeal.
  •  

  • Gather additional documentation and evidence with your healthcare provider to support your case, addressing the denial reasons directly.
  •  

  • Submit an appeal, following Highmark's specified procedure, and keep detailed records of all correspondence.

 

Explore Alternative Support Program

 

  • Investigate available patient assistance programs which might offer Liraglutide (Saxenda) at a reduced cost or through rebates, especially if repeated authorization attempts fail.
  •  

  • Discuss alternative medications or treatment strategies with your healthcare provider if cost remains an obstacle.

 

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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.

Each pharmacy in our network undergoes rigorous third-party testing through FDA and DEA certified labs. These tests focus on four key elements, ensuring both safety and efficacy for our treatments.

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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A weight management program tailored to you

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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