Does Sharp Health Plan Cover Lyrica

Explore why Sharp Health Plan might deny Lyrica, how to secure coverage, its costs without insurance, and get answers with this comprehensive guide.
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Coverage of Lyrica by Sharp Health Plan

 

  • Sharp Health Plan may cover Lyrica if it is deemed medically necessary. Members typically require prior authorization to ensure coverage.
  •  

  • Coverage is generally for conditions such as diabetic nerve pain, fibromyalgia, and partial onset seizures. The prescribing doctor must provide documentation supporting the necessity for Lyrica.
  •  

  • Members should confirm with Sharp Health Plan's formulary to verify if Lyrica is included and check for any specific requirements for coverage.
  •  

  • Eligibility and coverage may vary based on the specific plan type, so members should review their plan details or consult with a Sharp Health Plan representative for personalized information.

 

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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 Lyrica Coverage with Sharp Health Plan

 

Check Your Lyrica Prescription

 

  • Ensure that your prescription for Lyrica is filled out correctly by your healthcare provider. Double-check the dosage and frequency to align with your medical needs.
  •  

  • Confirm that Lyrica is included in Sharp Health Plan’s formulary. You can do this by visiting their website or contacting their customer service.

 

Review Sharp Health Plan’s Coverage

 

  • Visit the Sharp Health Plan website to access the latest drug formulary list. This document will indicate whether Lyrica is covered and any special coverage conditions.
  •  

  • Check for any tier listing for the drug. Knowing its tier can help you understand the co-payments or prior authorization requirements necessary.

 

Contact Sharp Health Plan Customer Service

 

  • Call Sharp Health Plan’s Member Services department using the contact information provided on your membership card. They can confirm Lyrica’s coverage status and detail what’s required for approval.
  •  

  • Inquire about the process for obtaining prior authorization if it's needed. They can provide a direct line or email to the prior authorization department.

 

Consult with Your Healthcare Provider

 

  • Before your healthcare provider writes the Lyrica prescription, share any details from Sharp Health Plan regarding necessary documentation for coverage.
  •  

  • If prior authorization is required, your healthcare provider may need to provide a letter of medical necessity or complete specific forms provided by Sharp Health Plan.

 

Submit a Prior Authorization Request

 

  • Work with your healthcare provider to fill out and submit any required prior authorization forms. Sharp Health Plan often requires medical justification for certain prescriptions.
  •  

  • Use the fax or electronic submission method suggested by Sharp Health Plan to ensure your request is received promptly.

 

Follow Up and Confirm Approval

 

  • After submission, follow up with both Sharp Health Plan and your healthcare provider to confirm that all necessary documentation has been received and processed.
  •  

  • Once approved, review any notification or approval letters sent by Sharp Health Plan to understand coverage terms and any associated costs.

 

Pick Up Your Prescription

 

  • Visit your local pharmacy with your Sharp Health Plan card to pick up your Lyrica prescription. Confirm that your coverage details are applied correctly at checkout.
  •  

  • If any issues arise at the pharmacy, contact Sharp Health Plan immediately to resolve them while ensuring you receive your medication on time.

 

Consider Options if Denied

 

  • If your request for Lyrica coverage is denied, ask Sharp Health Plan for detailed reasons and instructions on appealing the decision.
  •  

  • Consult with your healthcare provider to explore alternative medications that may be covered or to provide additional supporting information for an appeal.

 

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FAQs

Does Sharp Health Plan Cover Lyrica

Explore why Sharp Health Plan might deny Lyrica, how to secure coverage, its costs without insurance, and get answers with this comprehensive guide.
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Is Lyrica Covered by Sharp Health Plan

 

Coverage of Lyrica by Sharp Health Plan

 

  • Sharp Health Plan may cover Lyrica if it is deemed medically necessary. Members typically require prior authorization to ensure coverage.
  •  

  • Coverage is generally for conditions such as diabetic nerve pain, fibromyalgia, and partial onset seizures. The prescribing doctor must provide documentation supporting the necessity for Lyrica.
  •  

  • Members should confirm with Sharp Health Plan's formulary to verify if Lyrica is included and check for any specific requirements for coverage.
  •  

  • Eligibility and coverage may vary based on the specific plan type, so members should review their plan details or consult with a Sharp Health Plan representative for personalized information.

 

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Sharp Health Plan's Approved Criteria for Lyrica Coverage

 

Criteria for Lyrica Coverage under Sharp Health Plan

 

  • **Diagnosis Requirement:** The member must have a confirmed diagnosis of one of the following conditions for which Lyrica is approved: Neuropathic Pain associated with diabetic peripheral neuropathy, postherpetic neuralgia, fibromyalgia, neuropathic pain associated with spinal cord injury, or partial onset seizures in adults (as adjunctive therapy).
  •  

  • **Clinical Documentation:** Submission of clinical documentation indicating the diagnosis and previous treatment history is required. This should include history of pain management and prior therapies that were insufficiently effective or not tolerated.
  •  

  • **Previous Treatment:** The member must have tried and failed or have contraindications to at least two alternative pain management therapies. This could include nonsteroidal anti-inflammatory drugs (NSAIDs), gabapentin, or amitriptyline for neuropathic pain. For fibromyalgia, this might also include duloxetine or milnacipran.
  •  

  • **Prescription from Specialist:** Prescription of Lyrica must be made by or in consultation with a neurologist, pain specialist, or other appropriate specialist relevant to the patient's condition.
  •  

  • **Dose and Administration:** Requests for coverage must specify the recommended dose and ensure it fits within FDA-approved labeling or established guidelines for the particular condition being treated.
  •  

  • **Duration of Approval:** Initial coverage is typically granted for a trial period of three months to assess the efficacy and patient's response to the medication. Further authorization requires documentation of improvement in symptoms or functional status.
  •  

  • **Renewal Criteria:** Ongoing coverage may be approved upon submission of documentation showing positive response and continued need. The provider must provide evidence of clinical benefit and a note detailing continually assessed medical need.
  •  

 

Why Sharp Health Plan Might Deny Lyrica Coverage

 

Reasons for Denial of Lyrica Coverage

 

  • Lyrica is not covered if prescribed for off-label uses that are not approved by the FDA or the health plan’s policy.
  •  

  • Denial may occur if Lyrica is not deemed medically necessary according to Sharp Health Plan’s guidelines or if alternative therapies have not been tried or documented.
  •  

  • Coverage might be denied if the prescribing physician is not within Sharp Health Plan’s network, or if prior authorization was not obtained before obtaining the medication.
  •  

  • Sharp Health Plan may not cover Lyrica if documentation supporting clinical need or previous ineffective treatments is insufficient or not submitted.
  •  

  • Lyrica is not covered if used for conditions or symptoms not included in the approved diagnostic criteria outlined by the plan.
  •  

  • If the patient does not meet certain criteria regarding age, comorbid conditions, or other plan-specific requirements, Lyrica coverage might be denied.

 

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How Much Does Lyrica Cost without Insurance?

 

Cost of Lyrica Without Insurance

 

  • The price of Lyrica without insurance can vary significantly depending on the pharmacy, geographic location, dosage, and quantity. On average, the cost can range between $460 to $720 for a 30-day supply when filling a common dosage such as 150 mg capsules.
  •  

  • Generic versions of Lyrica, known as pregabalin, are often significantly cheaper. The average cost for the generic version might be closer to $30 to $70 for a similar quantity and dosage.
  •  

  • Prices may also vary due to manufacturer's discounts, pharmacy membership programs, or coupon usage, which can help reduce the overall cost.
  •  

  • Comparing prices between local pharmacies or using online price comparison tools can help find the most affordable option.

 

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 Lyrica Coverage with Sharp Health Plan

 

Check Your Lyrica Prescription

 

  • Ensure that your prescription for Lyrica is filled out correctly by your healthcare provider. Double-check the dosage and frequency to align with your medical needs.
  •  

  • Confirm that Lyrica is included in Sharp Health Plan’s formulary. You can do this by visiting their website or contacting their customer service.

 

Review Sharp Health Plan’s Coverage

 

  • Visit the Sharp Health Plan website to access the latest drug formulary list. This document will indicate whether Lyrica is covered and any special coverage conditions.
  •  

  • Check for any tier listing for the drug. Knowing its tier can help you understand the co-payments or prior authorization requirements necessary.

 

Contact Sharp Health Plan Customer Service

 

  • Call Sharp Health Plan’s Member Services department using the contact information provided on your membership card. They can confirm Lyrica’s coverage status and detail what’s required for approval.
  •  

  • Inquire about the process for obtaining prior authorization if it's needed. They can provide a direct line or email to the prior authorization department.

 

Consult with Your Healthcare Provider

 

  • Before your healthcare provider writes the Lyrica prescription, share any details from Sharp Health Plan regarding necessary documentation for coverage.
  •  

  • If prior authorization is required, your healthcare provider may need to provide a letter of medical necessity or complete specific forms provided by Sharp Health Plan.

 

Submit a Prior Authorization Request

 

  • Work with your healthcare provider to fill out and submit any required prior authorization forms. Sharp Health Plan often requires medical justification for certain prescriptions.
  •  

  • Use the fax or electronic submission method suggested by Sharp Health Plan to ensure your request is received promptly.

 

Follow Up and Confirm Approval

 

  • After submission, follow up with both Sharp Health Plan and your healthcare provider to confirm that all necessary documentation has been received and processed.
  •  

  • Once approved, review any notification or approval letters sent by Sharp Health Plan to understand coverage terms and any associated costs.

 

Pick Up Your Prescription

 

  • Visit your local pharmacy with your Sharp Health Plan card to pick up your Lyrica prescription. Confirm that your coverage details are applied correctly at checkout.
  •  

  • If any issues arise at the pharmacy, contact Sharp Health Plan immediately to resolve them while ensuring you receive your medication on time.

 

Consider Options if Denied

 

  • If your request for Lyrica coverage is denied, ask Sharp Health Plan for detailed reasons and instructions on appealing the decision.
  •  

  • Consult with your healthcare provider to explore alternative medications that may be covered or to provide additional supporting information for an appeal.

 

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Lyrica FAQ

What are the common side effects of Lyrica?

 

Common Side Effects of Lyrica

 

  • Dizziness: Frequently reported, often occurring shortly after starting treatment.
  • Sleepiness: Commonly affects daily activities due to its sedative effects.
  • Weight Gain: Notable for some, monitoring weight is advised.
  • Swelling: Particularly in hands and feet; may require medical attention if severe.
  • Blurred Vision: Usually temporary but should be reported if persistent.
  • Dry Mouth: Sometimes improved with increased fluid intake.
  • Difficulty concentrating: Can affect mental clarity and focus.

 

Is Lyrica the same as gabapentin?

 

Differences Between Lyrica and Gabapentin

 

  • Classification: Both are anticonvulsants but with different active ingredients. Lyrica contains pregabalin, while gabapentin itself is the active substance in gabapentin medications.
  •  

  • FDA Approval: Lyrica is approved for treating fibromyalgia, neuropathic pain, seizures, and generalized anxiety disorder in certain regions. Gabapentin's primary uses are for seizures and nerve pain.
  •  

  • Potency and Dosing: Lyrica is often considered more potent, requiring lower doses to achieve similar effects compared to gabapentin.
  •  

  • Side Effects: Both can cause dizziness and fatigue, but the severity and other side effects can vary between individuals.

 

Can Lyrica help with anxiety?

 

Understanding Lyrica and Anxiety

 

  • Lyrica (pregabalin) is primarily approved for treating nerve pain, fibromyalgia, and seizures.
  •  

  • Although not FDA-approved for anxiety, it has been used off-label to help some patients manage anxiety symptoms, especially in generalized anxiety disorder (GAD).

 

Mechanism and Effectiveness

 

  • Lyrica works by calming hyper-excited nerves, which may reduce anxiety symptoms by stabilizing neuronal activity.
  •  

  • Clinical studies suggest it can reduce anxiety more effectively than a placebo and comparable to some anxiety medications.

 

Considerations and Side Effects

 

  • Possible side effects include dizziness, sleepiness, and weight gain, which should be considered before off-label use.
  •  

  • Consult your doctor to assess if Lyrica aligns with your specific health needs and to discuss alternate anxiety treatments.

 

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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?

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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