Does SummaCare Cover Liraglutide (Saxenda)

Explore SummaCare coverage for Liraglutide (Saxenda), reasons for denial, tips to secure coverage, costs without insurance, and FAQs in this comprehensive guide.
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Coverage for Liraglutide (Saxenda) by SummaCare

 

  • **Eligibility**: SummaCare may cover Saxenda for individuals diagnosed with obesity or those who have weight-related health conditions. The coverage typically requires a prescription from a healthcare provider.
  •  

  • **Criteria**: Patients usually need to meet certain Body Mass Index (BMI) thresholds for eligibility. Often, a BMI of 30 or higher, or 27 with an accompanying condition, like hypertension or type 2 diabetes, is necessary.
  •  

  • **Prior Authorization**: Prior authorization might be required. This means that your doctor will need to verify with SummaCare that Saxenda is medically necessary, based on your health status and history.
  •  

  • **Documentation**: Medical documentation supporting the necessity of Saxenda for weight management or obesity-related issues will need to be provided.
  •  

  • **Prescription Coverage**: Saxenda coverage may fall under prescription drug benefits, implying your plan's formulary or tier system will impact your out-of-pocket costs.
  •  

  • **Stay Updated**: It’s crucial to continually check the specifics of your SummaCare plan, as coverage details and formularies can change.

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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 Liraglutide (Saxenda) Coverage with SummaCare

 

Verify Your Coverage

 

  • Check your SummaCare policy documents to determine if Liraglutide (Saxenda) is listed under your current formulary or prescription drug coverage.
  •  

  • Contact SummaCare customer service for direct confirmation. You can find their contact information on the back of your insurance card or via their official website.

 

Consult Your Healthcare Provider

 

  • Discuss your need for Liraglutide (Saxenda) with your healthcare provider. They should document your medical necessity for the medication.
  •  

  • Request a written prescription from your healthcare provider, specifying Liraglutide (Saxenda).

 

Obtain a Prior Authorization

 

  • Find out if a prior authorization is required by SummaCare for Liraglutide (Saxenda). This information can typically be obtained from SummaCare’s formulary guide or by calling customer service.
  •  

  • If required, have your healthcare provider initiate the prior authorization process. They may need to submit clinical information that supports the need for Liraglutide (Saxenda).

 

Submit a Claim

 

  • Ensure that your healthcare provider submits the prescription claim to SummaCare, including any required prior authorization documentation.
  •  

  • Verify that the pharmacy has all necessary details to process the coverage through SummaCare. They may need to contact SummaCare directly for any clarification.

 

Appeal if Necessary

 

  • If your claim is denied, review the denial letter carefully to understand the reason for denial.
  •  

  • Work with your healthcare provider to gather additional information or evidence that might support your need for Liraglutide (Saxenda).
  •  

  • Submit an appeal to SummaCare, following their specific appeal process noted in the denial letter or in their policy documentation.

 

Follow Up Regularly

 

  • Keep in contact with both your healthcare provider and SummaCare to track the status of your prior authorization, claim, or appeal.
  •  

  • Document all communications, as this may be useful if any further issues arise.
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FAQs

Does SummaCare Cover Liraglutide (Saxenda)

Explore SummaCare coverage for Liraglutide (Saxenda), reasons for denial, tips to secure coverage, costs without insurance, and FAQs in this comprehensive guide.
Curex allergy drops unboxing

Is Liraglutide (Saxenda) Covered by SummaCare

 

Coverage for Liraglutide (Saxenda) by SummaCare

 

  • **Eligibility**: SummaCare may cover Saxenda for individuals diagnosed with obesity or those who have weight-related health conditions. The coverage typically requires a prescription from a healthcare provider.
  •  

  • **Criteria**: Patients usually need to meet certain Body Mass Index (BMI) thresholds for eligibility. Often, a BMI of 30 or higher, or 27 with an accompanying condition, like hypertension or type 2 diabetes, is necessary.
  •  

  • **Prior Authorization**: Prior authorization might be required. This means that your doctor will need to verify with SummaCare that Saxenda is medically necessary, based on your health status and history.
  •  

  • **Documentation**: Medical documentation supporting the necessity of Saxenda for weight management or obesity-related issues will need to be provided.
  •  

  • **Prescription Coverage**: Saxenda coverage may fall under prescription drug benefits, implying your plan's formulary or tier system will impact your out-of-pocket costs.
  •  

  • **Stay Updated**: It’s crucial to continually check the specifics of your SummaCare plan, as coverage details and formularies can change.

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SummaCare's Approved Criteria for Liraglutide (Saxenda) Coverage

 

Eligibility for Liraglutide (Saxenda) Coverage

 

  • Member must have a body mass index (BMI) of 30 kg/m² or greater.
  •  

  • If the member's BMI is between 27 kg/m² and 29.9 kg/m², they must have at least one comorbid condition. Eligible comorbid conditions can include hypertension, type 2 diabetes, or dyslipidemia.

 

Previous Weight-Loss Efforts

 

  • Member should have previously attempted weight loss through a physician-supervised diet and exercise plan for at least six months without achieving adequate results.
  •  

  • Documentation of previous weight-loss efforts must be provided in the medical records submitted for review.

 

Prescribing Guidelines

 

  • Liraglutide (Saxenda) must be prescribed by a physician who specializes in obesity treatment or by a primary care provider with experience in managing obesity.
  •  

  • A treatment plan should include a reduced-calorie diet and an increased physical activity regimen, alongside medication use.

 

Monitoring and Follow-Up

 

  • Patients prescribed Liraglutide (Saxenda) should have regular follow-up visits with their healthcare provider to monitor progress, side effects, and adherence to the treatment plan.
  •  

  • Treatment efficacy should be evaluated after 16 weeks. If a weight reduction of at least 4% is not achieved, the continuation of treatment must be reassessed.

 

Duration of Coverage

 

  • Coverage approval is typically granted for an initial period of 16 weeks. Continued coverage may require documentation of significant weight loss, defined as a reduction in body weight by 4% or more.
  •  

  • Long-term therapy may be considered if the patient shows continued progress and meets coverage criteria during the initial treatment period.

 

Other Considerations

 

  • The physician must submit a prior authorization request with supporting documentation that details the member’s weight history, previous weight-loss efforts, and current health status.
  •  

  • All other concurrent medical conditions should be stable and well-managed prior to initiating treatment with Liraglutide (Saxenda).

 

Why SummaCare Might Deny Liraglutide (Saxenda) Coverage

 

Reasons for Denial of Liraglutide (Saxenda) Coverage by SummaCare

 

  • Liraglutide (Saxenda) is not covered for non-chronic weight management. If the medication is being requested for temporary weight loss or cosmetic purposes, coverage will be denied.
  •  

  • Requests lacking documentation of a formally diagnosed co-morbid condition such as type 2 diabetes, hypertension, or dyslipidemia. SummaCare requires evidence of such conditions for coverage approval.
  •  

  • The patient does not meet the required body mass index (BMI) criteria. For coverage, patients typically must have a BMI of 30 or greater, or 27 or greater with at least one weight-related co-morbid condition. Failure to meet these criteria will result in denial.
  •  

  • There is an exclusion for individuals under a certain age, as defined by SummaCare guidelines, due to lack of FDA approval for younger populations.
  •  

  • Prescription requests that lack a history of prior weight management intervention attempts. Patients must often demonstrate prior attempts at weight management, including lifestyle changes, diet, and exercise, without significant success.
  •  

  • SummaCare does not cover off-label use of Liraglutide (Saxenda). Coverage will be denied for uses not approved by the FDA or outside of recommended dosages unless explicitly included in the SummaCare policy.
  •  

  • Failure to submit required documentation through the proper channels. Requests improperly filed or missing vital information such as physician assessments or treatment history might not be processed or approved.
  •  

  • Requests already exceeding the authorized duration of use. SummaCare may have set limits on the duration that Liraglutide (Saxenda) can be covered by insurance.

 

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How Much Does Liraglutide (Saxenda) Cost without Insurance?

 

Liraglutide (Saxenda) Cost without Insurance

 

  • The cost of Liraglutide, commonly marketed under the brand name Saxenda, can vary based on location and pharmacy, but it typically ranges between $1,300 and $1,500 for a 30-day supply, which includes five injectable pens.
  •  

  • Prices can fluctuate due to factors like pharmacy pricing policies, manufacturer offers, and location. It is advisable to compare prices from various pharmacies or online sources.
  •  

  • Pharmacies may offer discount programs or coupons that could reduce the out-of-pocket cost. It's a good idea to inquire about available savings options.
  •  

  • Some online pharmacy platforms may provide competitive pricing and discounts, so checking these can be beneficial for finding better deals.
  •  

  • Prescription assistance programs, sometimes offered by the manufacturer, can provide help for individuals who meet certain income or insurance criteria. Exploring these options might also lead to cost savings.

 

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 Liraglutide (Saxenda) Coverage with SummaCare

 

Verify Your Coverage

 

  • Check your SummaCare policy documents to determine if Liraglutide (Saxenda) is listed under your current formulary or prescription drug coverage.
  •  

  • Contact SummaCare customer service for direct confirmation. You can find their contact information on the back of your insurance card or via their official website.

 

Consult Your Healthcare Provider

 

  • Discuss your need for Liraglutide (Saxenda) with your healthcare provider. They should document your medical necessity for the medication.
  •  

  • Request a written prescription from your healthcare provider, specifying Liraglutide (Saxenda).

 

Obtain a Prior Authorization

 

  • Find out if a prior authorization is required by SummaCare for Liraglutide (Saxenda). This information can typically be obtained from SummaCare’s formulary guide or by calling customer service.
  •  

  • If required, have your healthcare provider initiate the prior authorization process. They may need to submit clinical information that supports the need for Liraglutide (Saxenda).

 

Submit a Claim

 

  • Ensure that your healthcare provider submits the prescription claim to SummaCare, including any required prior authorization documentation.
  •  

  • Verify that the pharmacy has all necessary details to process the coverage through SummaCare. They may need to contact SummaCare directly for any clarification.

 

Appeal if Necessary

 

  • If your claim is denied, review the denial letter carefully to understand the reason for denial.
  •  

  • Work with your healthcare provider to gather additional information or evidence that might support your need for Liraglutide (Saxenda).
  •  

  • Submit an appeal to SummaCare, following their specific appeal process noted in the denial letter or in their policy documentation.

 

Follow Up Regularly

 

  • Keep in contact with both your healthcare provider and SummaCare to track the status of your prior authorization, claim, or appeal.
  •  

  • Document all communications, as this may be useful if any further issues arise.

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Liraglutide (Saxenda) FAQ

How much weight can you lose with Saxenda?

 

Weight Loss with Saxenda

 

  • Clinical trials show Saxenda users can lose an average of 5-10% of their initial body weight over 56 weeks.
  •  

  • Weight loss can vary depending on factors such as initial weight, diet, and physical activity.
  •  

  • Combining Saxenda with a reduced-calorie diet and increased physical activity enhances results.
  •  

  • It's important to monitor progress and consult with a healthcare provider to tailor the plan to individual needs.
  •  

  • Results are not guaranteed, and lifestyle changes significantly influence effectiveness.

What are the side effects of Liraglutide?

 

Common Side Effects

 

  • Nausea, particularly when starting treatment.
  • Vomiting or diarrhea, which can lead to dehydration.
  • Reduced appetite, a desired effect for weight management.
  • Headaches and dizziness, usually mild to moderate.

 

Serious Side Effects

 

  • Severe abdominal pain, signaling possible pancreatitis.
  • Symptoms of thyroid tumors, such as neck swelling or difficulty swallowing.
  • Serious allergic reactions, including hives or breath difficulty.
  • Elevated heart rate or palpitations.

 

Recommendations

 

  • Alert healthcare providers about any side effects.
  • Hydrate well to minimize dehydration from gastrointestinal effects.
  • Monitor blood sugar if diabetic, as levels may change.

 

How does Saxenda work for weight loss?

 

Mechanism of Action

 

  • Saxenda (liraglutide) is a GLP-1 receptor agonist. It mimics the action of the glucagon-like peptide-1, a hormone involved in appetite regulation.
  •  

  • It enhances insulin secretion and delays gastric emptying, promoting a feeling of fullness.

 

Appetite Suppression

 

  • Saxenda targets areas of the brain that control hunger, reducing appetite and calorie intake.
  •  

  • This helps in forming healthier eating habits and better portion control.

 

Additional Benefits

 

  • Besides weight loss, it assists in improving glycemic control for type 2 diabetes patients.
  •  

  • May lead to reductions in waist circumference and improvements in cardiovascular measures.

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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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