Does Horizon Blue Cross Blue Shield of New Jersey Cover Vyvanse

Explore Vyvanse coverage with Horizon BCBS NJ, reasons for denial, tips for approval, potential costs without insurance, and FAQs in this concise guide.
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Coverage for Vyvanse by Horizon BCBS NJ

 

  • Horizon Blue Cross Blue Shield of New Jersey generally covers Vyvanse as part of their pharmacy benefits, but coverage can vary based on your specific plan.
  •  

  • Prior authorization may be required. This means your doctor needs to provide clinical information about your diagnosis and treatment history.
  •  

  • Vyvanse is typically covered when prescribed for ADHD or binge eating disorder, when meeting Horizon BCBS NJ's medical necessity criteria.
  •  

  • Co-payment amounts and coverage details depend on whether Vyvanse is classified under Tier 1, 2, or 3 in your specific prescription plan.
  •  

  • Patients may need to try other medications first and demonstrate insufficient response or intolerable side effects before insurance approves Vyvanse.

 

Getting Vyvanse Covered

 

  • Consult your healthcare provider to discuss your medical need and obtain the necessary documentation for prior authorization.
  •  

  • Check your plan's formulary or contact Horizon BCBS NJ for up-to-date information on coverage and potential patient assistance programs for Vyvanse.

 

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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 Vyvanse Coverage with Horizon Blue Cross Blue Shield of New Jersey

 

Verify Your Plan Coverage

 

  • Log into your Horizon Blue Cross Blue Shield of New Jersey member account online. This will give you access to your specific plan details and coverage.
  •  

  • Review your plan documents, specifically the section regarding prescription medication coverage, to confirm if Vyvanse is included or requires prior authorization.
  •  

  • Contact Horizon's customer service for personalized assistance. They can confirm if Vyvanse is covered under your plan.

 

Consult Your Healthcare Provider

 

  • Discuss with your healthcare provider the medical necessity of Vyvanse for your condition. They will need to provide documentation to support your prescription.
  •  

  • Ensure that they understand the need for a detailed letter or prescription note that explains why Vyvanse is necessary for your treatment plan.

 

Submit Prior Authorization Request

 

  • If required, your healthcare provider will need to complete and submit a prior authorization form on your behalf. This form is typically available on the Horizon Blue Cross Blue Shield of New Jersey's provider portal.
  •  

  • Ensure all necessary documents and information are included, such as your medical history, diagnosis, and reasons for prescribing Vyvanse over other medications.

 

Follow Up on Authorization Status

 

  • Regularly check the status of your prior authorization request via your online member portal if Horizon offers this feature.
  •  

  • Contact Horizon's customer service or speak directly with your healthcare provider's office for updates on the authorization process.

 

Appeal a Denied Authorization

 

  • If your request is denied, Horizon Blue Cross Blue Shield of New Jersey will provide you with the reason for denial and steps for an appeal.
  •  

  • Gather any additional documentation that supports the need for Vyvanse and submit an appeal following the instructions provided by Horizon.

 

Check Out Prescription Discount Programs

 

  • If coverage remains an issue, consider checking for any prescription discount programs that can help lower the cost of Vyvanse. Many pharmaceutical companies offer savings cards or patient assistance programs.
  •  

  • Explore other available generic alternatives or discuss with your healthcare provider for recommendations based on your condition.

 

Use In-Network Pharmacies

 

  • Fill your Vyvanse prescription at pharmacies that are within Horizon's network to avoid additional costs that might not be reimbursed if you choose an out-of-network pharmacy.
  •  

  • Check any pharmacy benefit network restrictions or limitations tied to your plan that might affect where you can get your prescription filled.

 

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FAQs

Does Horizon Blue Cross Blue Shield of New Jersey Cover Vyvanse

Explore Vyvanse coverage with Horizon BCBS NJ, reasons for denial, tips for approval, potential costs without insurance, and FAQs in this concise guide.
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Is Vyvanse Covered by Horizon Blue Cross Blue Shield of New Jersey

 

Coverage for Vyvanse by Horizon BCBS NJ

 

  • Horizon Blue Cross Blue Shield of New Jersey generally covers Vyvanse as part of their pharmacy benefits, but coverage can vary based on your specific plan.
  •  

  • Prior authorization may be required. This means your doctor needs to provide clinical information about your diagnosis and treatment history.
  •  

  • Vyvanse is typically covered when prescribed for ADHD or binge eating disorder, when meeting Horizon BCBS NJ's medical necessity criteria.
  •  

  • Co-payment amounts and coverage details depend on whether Vyvanse is classified under Tier 1, 2, or 3 in your specific prescription plan.
  •  

  • Patients may need to try other medications first and demonstrate insufficient response or intolerable side effects before insurance approves Vyvanse.

 

Getting Vyvanse Covered

 

  • Consult your healthcare provider to discuss your medical need and obtain the necessary documentation for prior authorization.
  •  

  • Check your plan's formulary or contact Horizon BCBS NJ for up-to-date information on coverage and potential patient assistance programs for Vyvanse.

 

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Horizon Blue Cross Blue Shield of New Jersey's Approved Criteria for Vyvanse Coverage

 

Eligibility for Vyvanse Coverage

 

  • Patient must have a documented diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD) or Binge Eating Disorder (BED) as outlined in the DSM-5 criteria.
  •  

  • For ADHD, coverage is applicable for individuals aged 6 years and older. For BED, patients must be aged 18 years and older.
  •  

  • A comprehensive evaluation including medical history, physical exam, and mental health assessment must be performed by a licensed healthcare provider.

 

Prior Medication Use

 

  • The patient should have tried and failed, or had contraindications to, at least one other formulary stimulant or non-stimulant medication. This must be documented in the patient's medical records.
  •  

  • The healthcare provider must document the therapeutic goals established when the patient previously used medications, specifying why those medications were not effective or suitable.

 

Monitoring and Compliance

 

  • Prescriptions for Vyvanse must be provided by a licensed provider specializing in psychiatry, psychology, neurology, or another related field with experience managing ADHD or BED.
  •  

  • Regular follow-up visits must be scheduled to evaluate the effectiveness of Vyvanse, as well as to monitor for side effects and potential misuse. Documentation of these visits is necessary for continued coverage.
  •  

  • Patient adherence to the prescribed treatment plan, including appointment attendance and medication usage as directed, must be validated and documented.

 

Additional Documentation

 

  • The healthcare provider must document detailed clinical notes that justify the necessity of Vyvanse over other formulary alternatives, based on the specific medical needs and history of the patient.
  •  

  • Assessment of the patient's response and any adverse reactions to Vyvanse should be maintained and regularly updated in medical records.

 

Why Horizon Blue Cross Blue Shield of New Jersey Might Deny Vyvanse Coverage

 

Reasons Horizon Blue Cross Blue Shield of New Jersey Might Deny Vyvanse Coverage

 

  • **Off-label Use**: If Vyvanse is prescribed for a condition that is not FDA-approved, Horizon may decline coverage as it does not support off-label uses.
  •  

  • **Lack of Prior Authorization**: Coverage might be denied if prior authorization is required and not obtained. The insurance company requires this step to ensure the medication is necessary and appropriate for the patient.
  •  

  • **Non-compliance with Step Therapy Protocols**: If a patient has not tried and failed a less expensive medication first, as required by Horizon's step therapy process, Vyvanse might not be covered.
  •  

  • **Exceeds Age Limits**: Vyvanse prescriptions for patients outside of the approved age range for the medication might not be covered.
  •  

  • **Dose Exceeds Recommended Limits**: Prescriptions exceeding the dose commonly accepted as safe and effective are likely to be denied to ensure patient safety.
  •  

  • **Non-formulary Status**: If Vyvanse is not listed on Horizon’s formulary, it may not be covered unless an exception is granted due to medical necessity.
  •  

  • **Duplicate Therapy**: Coverage could be denied if Vyvanse is prescribed alongside another medication that Horizon considers redundant for the same condition.
  •  

  • **Insurance Policy Exclusions**: Coverage might be denied if Vyvanse is specifically excluded from coverage by the terms of the insurance policy.

 

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How Much Does Vyvanse Cost without Insurance?

 

Understanding the Cost of Vyvanse Without Insurance

 

  • Purchase prices for Vyvanse can vary depending on factors such as the dosage and the location of purchase. Typically, a 30-day supply of Vyvanse can price approximately between $350 and $500.
  •  

  • Costs might differ by pharmacy, with some options offering discounts or savings programs for those paying out-of-pocket.
  •  

  • It’s advisable to explore pharmacy discount cards or manufacturer copay assistance programs, as they can sometimes reduce the retail price.
  •  

  • Online pharmacy services may also present more competitive pricing, but always ensure they are reputable and that prescriptions are valid and properly filled.

 

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 Vyvanse Coverage with Horizon Blue Cross Blue Shield of New Jersey

 

Verify Your Plan Coverage

 

  • Log into your Horizon Blue Cross Blue Shield of New Jersey member account online. This will give you access to your specific plan details and coverage.
  •  

  • Review your plan documents, specifically the section regarding prescription medication coverage, to confirm if Vyvanse is included or requires prior authorization.
  •  

  • Contact Horizon's customer service for personalized assistance. They can confirm if Vyvanse is covered under your plan.

 

Consult Your Healthcare Provider

 

  • Discuss with your healthcare provider the medical necessity of Vyvanse for your condition. They will need to provide documentation to support your prescription.
  •  

  • Ensure that they understand the need for a detailed letter or prescription note that explains why Vyvanse is necessary for your treatment plan.

 

Submit Prior Authorization Request

 

  • If required, your healthcare provider will need to complete and submit a prior authorization form on your behalf. This form is typically available on the Horizon Blue Cross Blue Shield of New Jersey's provider portal.
  •  

  • Ensure all necessary documents and information are included, such as your medical history, diagnosis, and reasons for prescribing Vyvanse over other medications.

 

Follow Up on Authorization Status

 

  • Regularly check the status of your prior authorization request via your online member portal if Horizon offers this feature.
  •  

  • Contact Horizon's customer service or speak directly with your healthcare provider's office for updates on the authorization process.

 

Appeal a Denied Authorization

 

  • If your request is denied, Horizon Blue Cross Blue Shield of New Jersey will provide you with the reason for denial and steps for an appeal.
  •  

  • Gather any additional documentation that supports the need for Vyvanse and submit an appeal following the instructions provided by Horizon.

 

Check Out Prescription Discount Programs

 

  • If coverage remains an issue, consider checking for any prescription discount programs that can help lower the cost of Vyvanse. Many pharmaceutical companies offer savings cards or patient assistance programs.
  •  

  • Explore other available generic alternatives or discuss with your healthcare provider for recommendations based on your condition.

 

Use In-Network Pharmacies

 

  • Fill your Vyvanse prescription at pharmacies that are within Horizon's network to avoid additional costs that might not be reimbursed if you choose an out-of-network pharmacy.
  •  

  • Check any pharmacy benefit network restrictions or limitations tied to your plan that might affect where you can get your prescription filled.

 

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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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Vyvanse FAQ

What are the side effects of Vyvanse?

 

Common Side Effects

 

  • Loss of appetite
  • Insomnia
  • Dry mouth
  • Anxiety
  • Weight loss
  • Increased heart rate

 

Less Common Side Effects

 

  • Dizziness
  • Diarrhea
  • Rash
  • Blurred vision
  • Irritability

 

Serious Side Effects

 

  • Chest pain
  • Shortness of breath
  • Hallucinations
  • Severe anxiety or panic attacks
  • Swelling of extremities
  • Uncontrolled movements or vocal outbursts

 

Recommendations

 

  • Consult with a healthcare provider if side effects persist or worsen.
  • Monitor heart rate and blood pressure regularly.
  • Inform your doctor of any other medications being taken.

 

How long does Vyvanse stay in your system?

 

How Vyvanse Functions

 

  • Vyvanse is a prodrug, meaning it's inactive until metabolized in the body, which affects its duration.

 

Duration in the System

 

  • Vyvanse typically lasts 10-12 hours for therapeutic effects due to its extended-release formulation.
  • The half-life is around 10-13 hours, meaning it takes this time for half of the drug to be eliminated.

 

Detection Window

 

  • Blood: Detectable for up to 8 hours after ingestion.
  • Urine: Can be detected for up to 3 days, depending on metabolism and dosage.
  • Hair: May remain detectable for up to a month or longer.

 

Factors Influencing Duration

 

  • Metabolic rate, age, organ function, and dosage can alter the duration.
  • Chronic use may lead to accumulation, slightly extending the detectable period.

 

Is Vyvanse the same as Adderall?

 

Difference Between Vyvanse and Adderall

 

  • Composition: Vyvanse contains lisdexamfetamine, a prodrug requiring conversion in the body, while Adderall contains mixed amphetamine salts.
  •  

  • Onset: Vyvanse typically takes longer to start acting due to its prodrug nature, whereas Adderall provides quicker results.
  •  

  • Duration: Vyvanse lasts about 10-14 hours, while Adderall's duration varies based on the formulation: instant-release lasts 4-6 hours, extended-release lasts up to 12 hours.
  •  

  • Use: Both treat ADHD, but Vyvanse is also approved for binge eating disorder.
  •  

  • Abuse Potential: Vyvanse's requirement for metabolic activation reduces its immediate abuse risk compared to Adderall.

 

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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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