Does Highmark Cover Tirzepatide (Mounjaro)

Explore Highmark's coverage on Tirzepatide, ways to secure approval, costs without insurance, and get answers to common questions in our comprehensive guide.
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Highmark Coverage for Tirzepatide (Mounjaro)

 

  • Tirzepatide, marketed as Mounjaro, is covered by Highmark primarily for the treatment of type 2 diabetes.
  •  

  • Coverage is usually contingent on prior authorization, indicating a need for the drug due to inadequate control of blood sugar levels with other medications.
  •  

  • Patients may need to demonstrate a history of failure with other glucose-lowering medications, such as metformin, or intolerance to them.
  •  

  • Meeting specific health criteria, like a particular HbA1c level and a certain BMI, often plays a role in eligibility.
  •  

  • Decisions on coverage may vary based on individual policy details and the state Highmark operates in, so verifying with Highmark directly or consulting the member's specific plan benefits is advised.

 

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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.

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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.

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

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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 Tirzepatide (Mounjaro) Coverage with Highmark

 

Verify Eligibility and Coverage

 

  • Contact Highmark customer service to check if your plan covers prescription medications, specifically Tirzepatide (Mounjaro).
  •  

  • Use Highmark's online member portal to review your benefits and confirm prescription drug coverage details.

 

Consult with Your Healthcare Provider

 

  • Schedule an appointment to discuss your eligibility for Tirzepatide (Mounjaro) with your healthcare provider.
  •  

  • Request a detailed prescription that includes medical necessity for insurance approval.

 

Obtain Prior Authorization

 

  • Work with your healthcare provider to submit a prior authorization request to Highmark.
  •  

  • Ensure that all necessary medical documentation, such as diagnosis and prior treatments, is included.
  •  

  • Follow up with Highmark regularly to check the status of your prior authorization request.

 

Explore Discount Programs

 

  • Inquire about patient assistance programs or manufacturer discounts that may help reduce out-of-pocket costs.
  •  

  • Visit Mounjaro's official website to see if Eli Lilly offers any savings programs.

 

Appeals and Further Assistance

 

  • If your initial request is denied, ask Highmark for detailed reasons and prepare to submit an appeal with supporting documentation.
  •  

  • Contact Highmark’s customer service for help with the appeals process or to explore alternative coverage options.

 

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FAQs

Does Highmark Cover Tirzepatide (Mounjaro)

Explore Highmark's coverage on Tirzepatide, ways to secure approval, costs without insurance, and get answers to common questions in our comprehensive guide.
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Is Tirzepatide (Mounjaro) Covered by Highmark

 

Highmark Coverage for Tirzepatide (Mounjaro)

 

  • Tirzepatide, marketed as Mounjaro, is covered by Highmark primarily for the treatment of type 2 diabetes.
  •  

  • Coverage is usually contingent on prior authorization, indicating a need for the drug due to inadequate control of blood sugar levels with other medications.
  •  

  • Patients may need to demonstrate a history of failure with other glucose-lowering medications, such as metformin, or intolerance to them.
  •  

  • Meeting specific health criteria, like a particular HbA1c level and a certain BMI, often plays a role in eligibility.
  •  

  • Decisions on coverage may vary based on individual policy details and the state Highmark operates in, so verifying with Highmark directly or consulting the member's specific plan benefits is advised.

 

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Highmark's Approved Criteria for Tirzepatide (Mounjaro) Coverage

 

Highmark Approved Criteria for Tirzepatide (Mounjaro) Coverage

 

  • **Diagnosis Requirement**: Coverage is provided for patients diagnosed with Type 2 Diabetes Mellitus.
  •  

  • **Previous Treatment**: The patient must have demonstrated inadequate glycemic control with metformin, or other antidiabetic medications, unless metformin is contraindicated or not tolerated.
  •  

  • **Body Mass Index (BMI)**: In some cases, documentation of a BMI of 30 kg/m2 or greater may be required to qualify for coverage.
  •  

  • **Medical Records**: Submission of current medical records indicating treatment history and diabetes management is essential to verify the necessity of Tirzepatide.
  •  

  • **Age Requirement**: The patient must be 18 years of age or older to qualify for Tirzepatide coverage under Highmark's guidelines.
  •  

  • **Prescriber Specialty**: The prescription should be initiated by an endocrinologist or a healthcare provider specialized in managing diabetes.
  •  

  • **Comorbidity Factors**: Consideration of comorbidity factors such as cardiovascular disease may strengthen the case for prescribing Tirzepatide if noted in the patient's health records.
  •  

  • **Prior Authorization**: Highmark requires a prior authorization process to review and approve the use of Tirzepatide based on the criteria outlined.
  •  

  • **Dosage Compliance**: Coverage is contingent on adherence to the prescribed dosage regimen as per the healthcare provider's direction.

 

Why Highmark Might Deny Tirzepatide (Mounjaro) Coverage

 

Situations Where Highmark Does Not Cover Tirzepatide (Mounjaro)

 

  • Tirzepatide (Mounjaro) is not covered when prescribed for unauthorized or non-FDA-approved use cases that fall outside the established indications for the medication.
  •  

  • The medication is not covered if it is prescribed without adhering to the specific dosage requirements or without following the titration schedule as detailed by FDA approvals and guidelines.
  •  

  • It is not covered when there is a lack of documented clinical necessity, meaning there is insufficient medical evidence presented to justify its use for the specific prescribed condition.
  •  

  • Highmark may deny coverage if the patient does not meet the established clinical and diagnostic criteria, such as a certain body mass index (BMI) threshold, required for initiation of therapy.
  •  

  • Coverage is not provided if there is inadequate documentation of previous treatments or if alternative, more cost-effective treatments have not been attempted prior to prescribing Tirzepatide.
  •  

  • Highmark might deny coverage if the medication is obtained from a non-participating pharmacy or provider that is not within the Highmark network.
  •  

 

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How Much Does Tirzepatide (Mounjaro) Cost without Insurance?

 

Cost of Tirzepatide (Mounjaro) Without Insurance

 

  • The approximate cost of Tirzepatide, commonly known by its brand name Mounjaro, can vary based on several factors including the pharmacy location and any available discounts.
  •  

  • On average, the price for four doses of Mounjaro, which is typically a one-month supply, is estimated to be between $1,000 and $1,250 without any insurance coverage.
  •  

  • It's essential for patients to check with different pharmacies and consider available savings programs or manufacturer coupons which might offer significant reductions or discounts.
  •  

  • Additionally, some pharmacies might provide membership programs or discount cards that could further lower the 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 Tirzepatide (Mounjaro) Coverage with Highmark

 

Verify Eligibility and Coverage

 

  • Contact Highmark customer service to check if your plan covers prescription medications, specifically Tirzepatide (Mounjaro).
  •  

  • Use Highmark's online member portal to review your benefits and confirm prescription drug coverage details.

 

Consult with Your Healthcare Provider

 

  • Schedule an appointment to discuss your eligibility for Tirzepatide (Mounjaro) with your healthcare provider.
  •  

  • Request a detailed prescription that includes medical necessity for insurance approval.

 

Obtain Prior Authorization

 

  • Work with your healthcare provider to submit a prior authorization request to Highmark.
  •  

  • Ensure that all necessary medical documentation, such as diagnosis and prior treatments, is included.
  •  

  • Follow up with Highmark regularly to check the status of your prior authorization request.

 

Explore Discount Programs

 

  • Inquire about patient assistance programs or manufacturer discounts that may help reduce out-of-pocket costs.
  •  

  • Visit Mounjaro's official website to see if Eli Lilly offers any savings programs.

 

Appeals and Further Assistance

 

  • If your initial request is denied, ask Highmark for detailed reasons and prepare to submit an appeal with supporting documentation.
  •  

  • Contact Highmark’s customer service for help with the appeals process or to explore alternative coverage options.

 

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Tirzepatide (Mounjaro) FAQ

What are common side effects of Tirzepatide (Mounjaro)?

 

Common Side Effects of Tirzepatide (Mounjaro)

 

  • Nausea: Frequently reported, especially when starting treatment or increasing the dose.
  •  

  • Diarrhea: Some patients experience loose stools during treatment.
  •  

  • Decreased Appetite: Commonly occurs and can aid in weight management.
  •  

  • Vomiting: May happen occasionally, often alongside nausea.
  •  

  • Constipation: Some individuals might experience slower bowel movements.
  •  

  • Abdominal Pain: Discomfort or pain may occur during therapy.
  •  

  • Fatigue: A feeling of tiredness or exhaustion might present itself in some users.
  •  

  • In rare cases, hypoglycemia occurs, especially if combined with insulin or sulfonylureas.

 

How does Tirzepatide (Mounjaro) help with weight loss?

 

How Tirzepatide Aids Weight Loss

 

  • Dual Agonist Action: Tirzepatide acts on both GLP-1 and GIP receptors. These hormones help regulate appetite and glucose, influencing energy balance and metabolism.
  •  

  • Appetite Suppression: By mimicking these hormones, it reduces hunger, promoting lower calorie intake.
  •  

  • Increased Satiety: Delays gastric emptying, enhancing fullness and reducing meal frequency.
  •  

  • Improved Blood Sugar Control: Helps stabilize blood glucose levels, reducing insulin spikes that can stimulate hunger.
  •  

  • Enhanced Energy Expenditure: Modulates metabolic pathways to increase calorie burning, aiding fat loss.

 

Is Tirzepatide (Mounjaro) the same as Ozempic or Wegovy?

 

Comparing Tirzepatide with Ozempic and Wegovy

 

  • Composition: Tirzepatide (Mounjaro), Ozempic, and Wegovy are different medications. Tirzepatide is a dual GIP and GLP-1 receptor agonist, whereas Ozempic and Wegovy contain semaglutide, a GLP-1 receptor agonist.
  •  

  • Indications: Both Ozempic and Mounjaro target type 2 diabetes, but Wegovy is approved mainly for chronic weight management.
  •  

  • Mechanism: All induce insulin secretion and appetite suppression, yet Mounjaro's dual action may offer distinct benefits in glucose control and weight loss.
  •  

  • Dosage and Administration: Dosage forms and protocols vary; always follow medical guidance specific to the prescribed drug.
  •  

  • Considerations: Always consult your healthcare provider to determine the best option based on personal health needs and conditions.

 

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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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