Does SummaCare Cover Semaglutide (Wegovy)

Explore SummaCare's coverage on Semaglutide (Wegovy), learn denial reasons, ensure coverage, check costs without insurance, and find answers to FAQs.
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Coverage for Semaglutide (Wegovy)

 

  • SummaCare may cover Semaglutide (Wegovy) for individuals diagnosed with obesity, provided specific medical criteria are met. Coverage often requires prior authorization from the insurance provider.
  •  

  • The patient typically needs to have a documented body mass index (BMI) of 30 kg/m2 or greater, or 27 kg/m2 with at least one weight-related comorbidity like diabetes or hypertension.

 

Criteria for Coverage

 

  • A healthcare provider must demonstrate the medical necessity of Wegovy as part of a comprehensive weight management program, including a reduced calorie diet and increased physical activity.
  •  

  • The patient may be required to have attempted other weight-loss methods before Wegovy is considered for coverage.
  •  

  • Continuous eligibility might necessitate evidence of weight loss over time, evaluated through periodic review.

 

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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 SummaCare

 

Verify Your SummaCare Insurance Plan

 

  • Contact SummaCare customer service to confirm if Semaglutide (Wegovy) is included in your current plan.
  •  

  • Send an email or use the SummaCare online portal to check your coverage details and see if there are any associated requirements or pre-approvals needed.

 

Consult with Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss whether Semaglutide (Wegovy) is appropriate for your health needs.
  •  

  • Request your healthcare provider to provide any necessary documentation or medical history that demonstrates the need for the medication.

 

Submit a Pre-Authorization Request

 

  • Fill out any necessary forms required by SummaCare for medication coverage. These forms may require your healthcare provider's input or signature.
  •  

  • Submit the completed pre-authorization request along with any supporting documents like medical records through the online portal or via fax/mail to SummaCare.

 

Monitor the Approval Process

 

  • Follow up with SummaCare regularly to monitor the status of your pre-authorization request.
  •  

  • Reach out to your healthcare provider if SummaCare requests additional information or documentation to proceed with the approval.

 

Explore Financial Assistance Options

 

  • Contact SummaCare to find if there are any available cost-saving programs or discounts for prescription medications.
  •  

  • Inquire with your healthcare provider about pharmaceutical patient assistance programs that might offer Semaglutide (Wegovy) at a reduced rate.

 

Final Steps and Pickup

 

  • Once approval is confirmed, check with your pharmacy to ensure they have Semaglutide (Wegovy) in stock and understand how to bill it under your insurance plan.
  •  

  • Ensure you adhere to follow-up appointments and any usage instructions provided by your healthcare provider to maximize the effectiveness of the medication.

 

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FAQs

Does SummaCare Cover Semaglutide (Wegovy)

Explore SummaCare's coverage on Semaglutide (Wegovy), learn denial reasons, ensure coverage, check costs without insurance, and find answers to FAQs.
Curex allergy drops unboxing

Is Semaglutide (Wegovy) Covered by SummaCare

 

Coverage for Semaglutide (Wegovy)

 

  • SummaCare may cover Semaglutide (Wegovy) for individuals diagnosed with obesity, provided specific medical criteria are met. Coverage often requires prior authorization from the insurance provider.
  •  

  • The patient typically needs to have a documented body mass index (BMI) of 30 kg/m2 or greater, or 27 kg/m2 with at least one weight-related comorbidity like diabetes or hypertension.

 

Criteria for Coverage

 

  • A healthcare provider must demonstrate the medical necessity of Wegovy as part of a comprehensive weight management program, including a reduced calorie diet and increased physical activity.
  •  

  • The patient may be required to have attempted other weight-loss methods before Wegovy is considered for coverage.
  •  

  • Continuous eligibility might necessitate evidence of weight loss over time, evaluated through periodic review.

 

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SummaCare's Approved Criteria for Semaglutide (Wegovy) Coverage

 

Eligibility Criteria for Semaglutide (Wegovy) Coverage

 

  • Members must be 18 years of age or older.
  •  

  • Documentation of 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 such as hypertension, type 2 diabetes, or dyslipidemia.
  •  

  • Prior failure of appropriate weight management measures, including dietary adjustments, physical activity, and behavioral interventions, as documented by a healthcare provider.
  •  

  • Prescription by a licensed healthcare provider specializing in weight management or obesity treatment.

 

Required Documentation

 

  • Medical records indicating previous weight management attempts and outcomes, confirming compliance with prescribed lifestyle modifications.
  •  

  • A comprehensive assessment including patient weight history, relevant health metrics, and any comorbid conditions contributing to the need for medical intervention.

 

Continuation of Therapy

 

  • Reevaluation of patient after 16 weeks to assess response to treatment, requiring documentation of weight loss of at least 5% from baseline.
  •  

  • Continued documentation of adherence to lifestyle interventions, as well as monitoring for efficacy and safety according to the prescribing information for Semaglutide (Wegovy).

 

Why SummaCare Might Deny Semaglutide (Wegovy) Coverage

 

Reasons SummaCare Might Deny Semaglutide (Wegovy) Coverage

 

  • Semaglutide (Wegovy) is prescribed for a condition not approved by the FDA. SummaCare denies coverage if the drug is prescribed for off-label uses.
  •  

  • Failure to meet the specific BMI criteria established by SummaCare for coverage. Patients below the required BMI thresholds may be denied coverage.
  •  

  • The insured does not meet the necessary documented weight management attempts, such as a minimum of attempted lifestyle changes or other interventions.
  •  

  • Lack of a documented comorbid condition associated with obesity where coverage might be provided. Absence of conditions like Type 2 diabetes or hypertension may result in denials if they are part of the criteria.
  •  

  • Request for semaglutide (Wegovy) comes from an unapproved healthcare provider or lacks proper documentation from an authorized medical professional.
  •  

  • The prescribed dosage or treatment duration exceeds the limits set in the coverage policy guidelines of SummaCare.
  •  

  • Previous medication adherence issues or lack of compliance documentation can lead to coverage denial, especially if past prescriptions were not used as directed.
  •  

  • Generic alternatives are available or preferred under the plan, and if the provider does not justify the necessity for brand-name semaglutide (Wegovy), coverage may be denied.

 

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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 SummaCare

 

Verify Your SummaCare Insurance Plan

 

  • Contact SummaCare customer service to confirm if Semaglutide (Wegovy) is included in your current plan.
  •  

  • Send an email or use the SummaCare online portal to check your coverage details and see if there are any associated requirements or pre-approvals needed.

 

Consult with Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss whether Semaglutide (Wegovy) is appropriate for your health needs.
  •  

  • Request your healthcare provider to provide any necessary documentation or medical history that demonstrates the need for the medication.

 

Submit a Pre-Authorization Request

 

  • Fill out any necessary forms required by SummaCare for medication coverage. These forms may require your healthcare provider's input or signature.
  •  

  • Submit the completed pre-authorization request along with any supporting documents like medical records through the online portal or via fax/mail to SummaCare.

 

Monitor the Approval Process

 

  • Follow up with SummaCare regularly to monitor the status of your pre-authorization request.
  •  

  • Reach out to your healthcare provider if SummaCare requests additional information or documentation to proceed with the approval.

 

Explore Financial Assistance Options

 

  • Contact SummaCare to find if there are any available cost-saving programs or discounts for prescription medications.
  •  

  • Inquire with your healthcare provider about pharmaceutical patient assistance programs that might offer Semaglutide (Wegovy) at a reduced rate.

 

Final Steps and Pickup

 

  • Once approval is confirmed, check with your pharmacy to ensure they have Semaglutide (Wegovy) in stock and understand how to bill it under your insurance plan.
  •  

  • Ensure you adhere to follow-up appointments and any usage instructions provided by your healthcare provider to maximize the effectiveness of the medication.

 

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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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A weight management program tailored to you

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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