Does Oscar Health Cover Semaglutide (Wegovy)

Explore Oscar Health's coverage of Semaglutide (Wegovy), reasons for denial, ways to secure coverage, costs without insurance, and FAQs.
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Coverage for Semaglutide (Wegovy)

 

  • Oscar Health may cover Semaglutide (Wegovy) under certain conditions, primarily for patients diagnosed with obesity or weight-related issues.
  •  

  • Coverage typically requires prior authorization, meaning your healthcare provider must demonstrate medical necessity according to Oscar Health's criteria.

 

Criteria for Coverage

 

  • Patients often need to have a BMI over a specific threshold, commonly 30, or 27 with comorbid conditions like type 2 diabetes or hypertension.
  •  

  • Documentation of previous unsuccessful weight-loss attempts through diet and exercise may be required.

 

Basic Rules

 

  • It's essential to verify with Oscar Health directly or through their online portal, as coverage can vary based on plan and state regulations.
  •  

  • Consultation with a healthcare professional is advised to determine if Semaglutide is a suitable option for you and to facilitate the authorization process.

 

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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 Semaglutide (Wegovy) Coverage with Oscar Health

 

Understand Your Oscar Health Plan

 

  • Review your specific Oscar Health insurance policy to check coverage details for medications like Semaglutide (Wegovy). Look for terms related to prescription coverage and prior authorization requirements.
  •  

  • Make note of your plan's deductible, copayments, and any limits on pharmaceutical benefits, particularly concerning weight-management medications.

 

Consult with Your Healthcare Provider

 

  • Discuss with your doctor about your need for Wegovy and confirm it's the right medication for your condition. Ensure they document medical necessity, which is crucial for insurance purposes.
  •  

  • Ask your healthcare provider if they have experience with Oscar Health and are aware of the required documentation or procedures needed for prescription approval.

 

Submit Prior Authorization

 

  • Work with your physician to submit a prior authorization request to Oscar Health. This procedure is often necessary for weight-loss drugs like Semaglutide (Wegovy).
  •  

  • Ensure the request includes your medical history, diagnosis, and any other compelling reasons why Wegovy is necessary for your health management.

 

Follow-Up with Oscar Health

 

  • Contact Oscar Health customer service to confirm the status of your prior authorization request. Persistence and follow-ups can expedite the approval process.
  •  

  • Provide any additional information or documentation that Oscar Health might request to finalize the authorization for coverage.

 

Check Pharmacy Benefits

 

  • Once approved, verify which pharmacies are in-network with Oscar Health to fill your prescription. Confirm whether Wegovy is covered and find out your share of the cost after insurance.
  •  

  • Consider using Oscar Health’s mail-order pharmacy services for possibly reduced costs on your Semaglutide (Wegovy) prescription if it's an available option.

 

Appeal if Necessary

 

  • If your request is denied, don't hesitate to file an appeal. Work with your physician to prepare additional documentation or explanation to support your case.
  •  

  • Check Oscar Health's denial letter for information on the appeal process and work within their timeline to avoid missing deadlines.

 

Stay Informed

 

  • Keep up-to-date with any policy changes by Oscar Health that could affect your coverage of Semaglutide (Wegovy). Be proactive in understanding any new benefits or adjustments that might impact your treatment plan.
  •  

  • Regularly communicate with your healthcare provider to evaluate the continued necessity and effectiveness of the treatment, which might affect ongoing coverage support.

 

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FAQs

Does Oscar Health Cover Semaglutide (Wegovy)

Explore Oscar Health's coverage of Semaglutide (Wegovy), reasons for denial, ways to secure coverage, costs without insurance, and FAQs.
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Is Semaglutide (Wegovy) Covered by Oscar Health

 

Coverage for Semaglutide (Wegovy)

 

  • Oscar Health may cover Semaglutide (Wegovy) under certain conditions, primarily for patients diagnosed with obesity or weight-related issues.
  •  

  • Coverage typically requires prior authorization, meaning your healthcare provider must demonstrate medical necessity according to Oscar Health's criteria.

 

Criteria for Coverage

 

  • Patients often need to have a BMI over a specific threshold, commonly 30, or 27 with comorbid conditions like type 2 diabetes or hypertension.
  •  

  • Documentation of previous unsuccessful weight-loss attempts through diet and exercise may be required.

 

Basic Rules

 

  • It's essential to verify with Oscar Health directly or through their online portal, as coverage can vary based on plan and state regulations.
  •  

  • Consultation with a healthcare professional is advised to determine if Semaglutide is a suitable option for you and to facilitate the authorization process.

 

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Oscar Health's Approved Criteria for Semaglutide (Wegovy) Coverage

 

Eligibility Criteria for Semaglutide (Wegovy) Coverage

 

  • Patient must be 18 years or older.
  •  

  • Diagnosis of obesity, defined as a body mass index (BMI) of 30 kg/m² or greater, or a diagnosis of overweight, defined as a BMI of 27 kg/m² or greater in the presence of at least one weight-related comorbidity.
  •  

  • Comorbidities that may qualify include, but are not limited to, hypertension, type 2 diabetes mellitus, or dyslipidemia.

 

Prior Authorization Requirements

 

  • Documentation of a trial and failure, intolerance, or contraindication to other weight management interventions, including lifestyle modifications such as diet, exercise, and behavioral changes.
  •  

  • A recent comprehensive metabolic panel (CMP) and hemoglobin A1c test results, when applicable, should be included in the medical record.

 

Continued Therapy Criteria

 

  • Reevaluation of the patient’s BMI and weight must be conducted at 3 months post-therapy initiation to assess efficacy. Documentation should demonstrate at least a 4% weight reduction from baseline.
  •  

  • Regular follow-ups every 6 months thereafter to document the physical and metabolic improvements, with reviews from the prescribing healthcare provider to determine the ongoing necessity of treatment.
  •  

  • Confirmation that the patient continues prescribed lifestyle interventions in conjunction with Semaglutide therapy.

 

Dosage and Formulation

 

  • Covers subcutaneous injection of Semaglutide (Wegovy) as per the FDA-approved dosage schedule.
  •  

  • Treatment must be prescribed by a qualified healthcare provider, specializing in endocrinology or weight management, when applicable.

 

Why Oscar Health Might Deny Semaglutide (Wegovy) Coverage

 

Exclusion Criteria for Semaglutide (Wegovy) Coverage by Oscar Health

 

  • Individuals without a clinical diagnosis of obesity, typically defined as a BMI of 30 or higher, or a BMI of 27 or higher with weight-related comorbidities.
  •  

  • Patients using Semaglutide (Wegovy) for non-FDA-approved uses, including general weight management without appropriate medical indications.
  •  

  • Members who have not followed the required pre-authorization process or provided necessary clinical documentation supporting the medical necessity of treatment.
  •  

  • Patients who are on other conflicting or contraindicated medications that could pose a risk when combined with Semaglutide (Wegovy).
  •  

  • Individuals with a medical history that includes specific contraindications, such as personal or family history of certain thyroid cancers or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).
  •  

  • Claims submitted for doses exceeding the FDA-approved dosage limits for Semaglutide (Wegovy).
  •  

  • Coverage requests made during the waiting period before insurance activation or for individuals whose policies do not cover this particular medication.

 

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How Much Does Semaglutide (Wegovy) Cost without Insurance?

 

Approximate Cost of Semaglutide (Wegovy) Without Insurance

 

  • The price of Semaglutide, commonly known as Wegovy, without insurance can be substantial, typically ranging between $1,200 and $1,400 for a supply that lasts approximately one month.
  •  

  • This medication is designed for long-term weight management, thus planning financially for sustained use is important if paying out of pocket.
  •  

  • It's important to note that prices can vary based on the pharmacy, geographic location, and available discounts or pharmacy loyalty programs.
  •  

  • Patients are encouraged to seek patient assistance programs or discounts to help mitigate costs. Some pharmaceutical manufacturers offer discount cards or assistance programs to help with the cost of prescription medications like Wegovy.

 

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 Semaglutide (Wegovy) Coverage with Oscar Health

 

Understand Your Oscar Health Plan

 

  • Review your specific Oscar Health insurance policy to check coverage details for medications like Semaglutide (Wegovy). Look for terms related to prescription coverage and prior authorization requirements.
  •  

  • Make note of your plan's deductible, copayments, and any limits on pharmaceutical benefits, particularly concerning weight-management medications.

 

Consult with Your Healthcare Provider

 

  • Discuss with your doctor about your need for Wegovy and confirm it's the right medication for your condition. Ensure they document medical necessity, which is crucial for insurance purposes.
  •  

  • Ask your healthcare provider if they have experience with Oscar Health and are aware of the required documentation or procedures needed for prescription approval.

 

Submit Prior Authorization

 

  • Work with your physician to submit a prior authorization request to Oscar Health. This procedure is often necessary for weight-loss drugs like Semaglutide (Wegovy).
  •  

  • Ensure the request includes your medical history, diagnosis, and any other compelling reasons why Wegovy is necessary for your health management.

 

Follow-Up with Oscar Health

 

  • Contact Oscar Health customer service to confirm the status of your prior authorization request. Persistence and follow-ups can expedite the approval process.
  •  

  • Provide any additional information or documentation that Oscar Health might request to finalize the authorization for coverage.

 

Check Pharmacy Benefits

 

  • Once approved, verify which pharmacies are in-network with Oscar Health to fill your prescription. Confirm whether Wegovy is covered and find out your share of the cost after insurance.
  •  

  • Consider using Oscar Health’s mail-order pharmacy services for possibly reduced costs on your Semaglutide (Wegovy) prescription if it's an available option.

 

Appeal if Necessary

 

  • If your request is denied, don't hesitate to file an appeal. Work with your physician to prepare additional documentation or explanation to support your case.
  •  

  • Check Oscar Health's denial letter for information on the appeal process and work within their timeline to avoid missing deadlines.

 

Stay Informed

 

  • Keep up-to-date with any policy changes by Oscar Health that could affect your coverage of Semaglutide (Wegovy). Be proactive in understanding any new benefits or adjustments that might impact your treatment plan.
  •  

  • Regularly communicate with your healthcare provider to evaluate the continued necessity and effectiveness of the treatment, which might affect ongoing coverage support.

 

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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.

Semaglutide (Wegovy) FAQ

1. What are the common side effects of Semaglutide (Wegovy)?

 

Common Side Effects of Semaglutide (Wegovy)

 

  • Nausea  — Often occurs at the start of treatment and may decrease over time.
  •  

  • Vomiting  — Related to gastrointestinal upset; usually temporary.
  •  

  • Diarrhea  — Common and may vary in intensity.
  •  

  • Constipation  — It can occur alongside other digestive issues.
  •  

  • Abdominal Pain  — Includes discomfort or cramping sensation.
  •  

  • Headache  — Typically mild but can be persistent.
  •  

  • Dizziness  — May affect balance or result in vertigo-like symptoms.
  •  

  • Fatigue  — Some patients report general tiredness or lack of energy.

 

2. How much weight can I lose with Semaglutide (Wegovy)?

 

Potential Weight Loss with Semaglutide (Wegovy)

 

  • Clinical trials demonstrate that Semaglutide (Wegovy) helps individuals lose a significant amount of weight. On average, participants experienced a weight loss of about 15% of their initial body weight over 68 weeks.
  •  

  • Results vary, with some losing more and others less. Factors include adherence to medication, lifestyle changes, and individual metabolic responses.
  •  

  • Semaglutide should be part of a comprehensive weight management program, including a reduced-calorie diet and increased physical activity.
  •  

  • Consult with a healthcare professional for personalized advice and to discuss possible side effects like nausea or gastrointestinal issues.

 

3. Is Wegovy the same as Ozempic?

 

Differences Between Wegovy and Ozempic

 

  • Formulation: Both contain semaglutide, a GLP-1 receptor agonist, but are formulated for different purposes.
  •  

  • Indication: Wegovy is primarily for weight management in adults with obesity. Ozempic is prescribed for type 2 diabetes management.
  •  

  • Dosage: While both are weekly injections, Wegovy generally has higher dosing than Ozempic (up to 2.4mg vs. 1mg for Ozempic).
  •  

  • Side Effects: Common side effects overlap, including nausea, but may vary in intensity due to different dosages.

 

Conclusion

 

  • Though similar, they serve distinct medical purposes. Always consult your healthcare provider for personalized advice.

 

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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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