Does Scripps Health Cover Tirzepatide (Mounjaro)

Explore Tirzepatide coverage by Scripps Health. Learn denial reasons, coverage strategies, costs without insurance, and get answers to common questions.
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Does Scripps Health Cover Tirzepatide (Mounjaro)?

 

  • Scripps Health may cover Tirzepatide (Mounjaro) based on medical necessity and approval criteria.
  •  

  • Coverage is typically for type 2 diabetes patients who have not achieved glycemic control with other medications.
  •  

  • Prior authorization is required to determine eligibility and necessity.

 

Criteria for Coverage

 

  • Patients must be diagnosed with type 2 diabetes.
  •  

  • Failure to achieve adequate control with multiple other antidiabetic therapies.
  •  

  • Healthcare provider must provide detailed medical history and current treatment plan.

 

Basic Rules

 

  • Pre-approval from Scripps Health might be necessary before starting the treatment.
  •  

  • Regular monitoring and follow-ups with healthcare providers are mandated to ensure the drug's effectiveness.

 

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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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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 Scripps Health

 

Check Tirzepatide (Mounjaro) Coverage with Your Current Plan

 

  • Contact your health insurance provider to verify if Tirzepatide (Mounjaro) is covered under your current plan. Use your member portal or call the customer service number on the back of your insurance card.
  •  

  • Review your prescription drug coverage documents that came with your health insurance policy to find any specific details about coverage for diabetes medications.

 

Consult with a Scripps Health Physician

 

  • Schedule an appointment with a Scripps Health primary care physician or specialist. Discuss the potential need for Tirzepatide and any other treatment plans for managing your health condition.
  •  

  • Request that your physician provide a medical necessity letter if they believe Tirzepatide is essential for your treatment, which can aid in justifying insurance coverage.

 

Look into Formulary Resources at Scripps Health

 

  • Access Scripps Health’s formulary list via their official website or request this information during your visit. The formulary will indicate whether Tirzepatide is a preferred drug and outline any prerequisites or alternatives.
  •  

  • Ask Scripps Health staff about any available patient assistance programs or discounts for Tirzepatide.

 

Submit a Prior Authorization Request

 

  • If required, work with your Scripps Health physician to submit a prior authorization request. This is a formal process whereby the insurance company evaluates the necessity of the medication before agreeing to cover it.
  •  

  • Ensure that all documentation, such as the medical necessity letter and any supporting medical records, are included to strengthen your request.

 

Explore Alternative Funding Options

 

  • If insurance coverage is denied, check if external patient assistance programs like those offered by pharmaceutical companies can help subsidize the cost of Tirzepatide.
  •  

  • Discuss payment plans or financial assistance options with Scripps Health’s billing department to manage out-of-pocket expenses, if needed.

 

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FAQs

Does Scripps Health Cover Tirzepatide (Mounjaro)

Explore Tirzepatide coverage by Scripps Health. Learn denial reasons, coverage strategies, costs without insurance, and get answers to common questions.
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Is Tirzepatide (Mounjaro) Covered by Scripps Health

 

Does Scripps Health Cover Tirzepatide (Mounjaro)?

 

  • Scripps Health may cover Tirzepatide (Mounjaro) based on medical necessity and approval criteria.
  •  

  • Coverage is typically for type 2 diabetes patients who have not achieved glycemic control with other medications.
  •  

  • Prior authorization is required to determine eligibility and necessity.

 

Criteria for Coverage

 

  • Patients must be diagnosed with type 2 diabetes.
  •  

  • Failure to achieve adequate control with multiple other antidiabetic therapies.
  •  

  • Healthcare provider must provide detailed medical history and current treatment plan.

 

Basic Rules

 

  • Pre-approval from Scripps Health might be necessary before starting the treatment.
  •  

  • Regular monitoring and follow-ups with healthcare providers are mandated to ensure the drug's effectiveness.

 

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Scripps Health's Approved Criteria for Tirzepatide (Mounjaro) Coverage

 

Eligibility Criteria for Tirzepatide (Mounjaro) Coverage

 

  • Patient must have a documented diagnosis of type 2 diabetes mellitus.
  •  

  • Patient is 18 years of age or older.
  •  

  • Patient has a body mass index (BMI) of 30 kg/m² or greater, or a BMI of 27 kg/m² or greater with at least one weight-related comorbidity.
  •  

  • Patient has tried and had an inadequate response to at least two other antidiabetic medications. This may include metformin, sulfonylureas, or insulin.
  •  

  • Tirzepatide is prescribed by a healthcare provider specializing in endocrinology or diabetes management.
  •  

 

Specific Treatment Considerations

 

  • The treatment plan is in accordance with current clinical guidelines for the management of type 2 diabetes and has been documented in the patient's medical records.
  •  

  • Regular follow-up and monitoring plan have been established to assess the efficacy and safety of tirzepatide.
  •  

 

Required Documentation

 

  • Patient's recent medical history that includes the diagnosis of type 2 diabetes.
  •  

  • Records of previous antidiabetic treatments and their outcomes.
  •  

  • The current treatment plan detailing the use of tirzepatide.
  •  

  • Proof of the prescriber's specialization if requested.
  •  

 

Clinical Monitoring and Follow-up

 

  • Initial patient evaluation and follow-up appointments are planned to occur every three months.
  •  

  • Hemoglobin A1c (HbA1c) levels will be monitored at baseline and during follow-up to gauge treatment effectiveness.
  •  

  • Monitoring for potential side effects of tirzepatide, including gastrointestinal symptoms, is in place.
  •  

 

Why Scripps Health Might Deny Tirzepatide (Mounjaro) Coverage

 

Criteria for Denial of Coverage for Tirzepatide (Mounjaro)

 

  • Prescription of Tirzepatide is not in accordance with the FDA-approved indications or guidelines. If the usage is for an off-label condition not supported by medical necessity documentation, coverage may be denied.
  •  

  • Patients do not meet the specific clinical criteria set by Scripps Health for the use of Tirzepatide. This may include inadequate documented evidence of the patient's failure to respond to alternative, more cost-effective treatments.
  •  

  • Insufficient documentation provided. If healthcare providers fail to submit necessary medical records, assessments, or justification for prescribing Tirzepatide, the request for coverage may be rejected.
  •  

  • Coverage exclusions in the patient's specific health plan. If Tirzepatide is not included in the formulary or is specifically excluded from coverage, the request may be denied.
  •  

  • Lack of prior authorization. Scripps Health might require prior authorization, and if this step is not completed or is denied, coverage for the medication will not be provided.
  •  

  • Non-compliance with Scripps Health's medication review and approval processes. Any deviations from these processes could result in a coverage denial.

 

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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 Scripps Health

 

Check Tirzepatide (Mounjaro) Coverage with Your Current Plan

 

  • Contact your health insurance provider to verify if Tirzepatide (Mounjaro) is covered under your current plan. Use your member portal or call the customer service number on the back of your insurance card.
  •  

  • Review your prescription drug coverage documents that came with your health insurance policy to find any specific details about coverage for diabetes medications.

 

Consult with a Scripps Health Physician

 

  • Schedule an appointment with a Scripps Health primary care physician or specialist. Discuss the potential need for Tirzepatide and any other treatment plans for managing your health condition.
  •  

  • Request that your physician provide a medical necessity letter if they believe Tirzepatide is essential for your treatment, which can aid in justifying insurance coverage.

 

Look into Formulary Resources at Scripps Health

 

  • Access Scripps Health’s formulary list via their official website or request this information during your visit. The formulary will indicate whether Tirzepatide is a preferred drug and outline any prerequisites or alternatives.
  •  

  • Ask Scripps Health staff about any available patient assistance programs or discounts for Tirzepatide.

 

Submit a Prior Authorization Request

 

  • If required, work with your Scripps Health physician to submit a prior authorization request. This is a formal process whereby the insurance company evaluates the necessity of the medication before agreeing to cover it.
  •  

  • Ensure that all documentation, such as the medical necessity letter and any supporting medical records, are included to strengthen your request.

 

Explore Alternative Funding Options

 

  • If insurance coverage is denied, check if external patient assistance programs like those offered by pharmaceutical companies can help subsidize the cost of Tirzepatide.
  •  

  • Discuss payment plans or financial assistance options with Scripps Health’s billing department to manage out-of-pocket expenses, if needed.

 

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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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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.

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Do your plans include prescriptions and medications?

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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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