Does SummaCare Cover Tirzepatide (Mounjaro)

Explore if SummaCare covers Tirzepatide (Mounjaro), ways to secure coverage, out-of-pocket costs, and FAQs in this comprehensive guide.
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Tirzepatide (Mounjaro) Coverage by SummaCare

 

  • SummaCare may cover Tirzepatide (Mounjaro), commonly for adult patients with Type 2 diabetes who don't respond adequately to other treatments.
  •  

  • Coverage is typically subject to prior authorization, requiring a documented history of unsuccessful results with alternative medications for diabetes management.
  •  

  • Coverage might depend on the formulary tier placement, which influences out-of-pocket costs. Checking the latest formulary list or consulting with SummaCare directly is advised.
  •  

  • Eligibility often requires confirmation that the medication is medically necessary, validated by a healthcare provider's documentation aligning with SummaCare’s policy.
  •  

  • Patients may need to meet specific clinical criteria set by SummaCare, including a diagnosis from a healthcare provider along with a detailed treatment plan.
  •  

  • For comprehensive coverage details, SummaCare members should contact customer service to clarify conditions applicable to their individual plan.

 

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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.

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 SummaCare

 

Determine Eligibility for Tirzepatide Coverage

 

  • Consult SummaCare’s formulary to see if Tirzepatide (Mounjaro) is included. This helps understand the specific requirements and coverage details.
  • Review your specific plan benefits to verify if there are any additional criteria or conditions for coverage.
  • Check if there are any prior authorization requirements before obtaining the medication.

 

Consult Your Healthcare Provider

 

  • Discuss with your healthcare provider about the necessity of Tirzepatide for your condition.
  • Have your healthcare provider provide necessary documentation or explanation to support the use of Tirzepatide for you.
  • Ensure your provider is aware of any specific details required by SummaCare for coverage.

 

Contact SummaCare

 

  • Reach out to SummaCare customer service via their contact number provided on your insurance card.
  • Discuss Tirzepatide (Mounjaro) specifically, and inquire about any additional steps needed for coverage approval.
  • Ask about any forms or documentation needed from both your end and the healthcare provider to support the request.

 

Submit Prior Authorization, If Necessary

 

  • Complete any required prior authorization forms, which might often need input from your healthcare provider.
  • Submit the completed forms along with any required medical documentation or justifications.
  • Follow up with both SummaCare and your healthcare provider to ensure the prior authorization request is processed in a timely manner.

 

Review Approval and Fill Prescription

 

  • Upon receiving approval, review any specific instructions regarding co-pays or pharmacy networks where you can fill your prescription.
  • Visit an in-network pharmacy or use the specified pharmacy service as advised by SummaCare.
  • Fill your prescription for Tirzepatide and adhere to your prescribed treatment plan.

 

Appeal If Denied Coverage

 

  • If coverage is denied, request a detailed explanation for the decision from SummaCare.
  • Work with your healthcare provider to prepare additional documentation or justification to support your appeal.
  • Submit the appeal following SummaCare's specified processes, and keep track of any deadlines or requirements.

 

Regularly Review Insurance Plan

 

  • Annually review your SummaCare plan during the open enrollment period to ensure it continues to meet your medical needs, particularly regarding medications like Tirzepatide.
  • Consider changes or alternatives if your current plan’s coverage changes or if it no longer offers the support you need for your medications.

 

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FAQs

Does SummaCare Cover Tirzepatide (Mounjaro)

Explore if SummaCare covers Tirzepatide (Mounjaro), ways to secure coverage, out-of-pocket costs, and FAQs in this comprehensive guide.
Curex allergy drops unboxing

Is Tirzepatide (Mounjaro) Covered by SummaCare

 

Tirzepatide (Mounjaro) Coverage by SummaCare

 

  • SummaCare may cover Tirzepatide (Mounjaro), commonly for adult patients with Type 2 diabetes who don't respond adequately to other treatments.
  •  

  • Coverage is typically subject to prior authorization, requiring a documented history of unsuccessful results with alternative medications for diabetes management.
  •  

  • Coverage might depend on the formulary tier placement, which influences out-of-pocket costs. Checking the latest formulary list or consulting with SummaCare directly is advised.
  •  

  • Eligibility often requires confirmation that the medication is medically necessary, validated by a healthcare provider's documentation aligning with SummaCare’s policy.
  •  

  • Patients may need to meet specific clinical criteria set by SummaCare, including a diagnosis from a healthcare provider along with a detailed treatment plan.
  •  

  • For comprehensive coverage details, SummaCare members should contact customer service to clarify conditions applicable to their individual plan.

 

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SummaCare's Approved Criteria for Tirzepatide (Mounjaro) Coverage

 

SummaCare Coverage Criteria for Tirzepatide (Mounjaro)

 

  • The individual has a confirmed diagnosis of type 2 diabetes mellitus.
  •  

  • The prescribing healthcare provider is either an endocrinologist, diabetes specialist, or a primary care physician who is adept in managing diabetes.
  •  

  • The patient is 18 years of age or older.
  •  

  • The patient has a demonstrated intolerance, contraindication, or insufficient response to at least one other antidiabetic agent such as metformin, sulfonylureas, or a thiazolidinedione.
  •  

  • Documentation of lifestyle interventions attempted, including diet modification and physical exercise, which have not achieved adequate glycemic control.
  •  

  • The patient has an HbA1c level of 7.0% or higher, corroborated by lab results within the past 3 months.
  •  

  • There should be no evidence of type 1 diabetes mellitus or diabetic ketoacidosis.
  •  

  • Tirzepatide is prescribed as part of a comprehensive diabetes management plan, including dietary and lifestyle modifications.
  •  

  • The patient should not be currently on any other GLP-1 receptor agonists or DPP-4 inhibitors.
  •  

  • Continued coverage is contingent upon evidence of clinical benefit as assessed by a decrease in HbA1c or improvement in other clinical or metabolic parameters.

 

Required Documentation

 

  • Recent HbA1c test results and other relevant laboratory reports.
  •  

  • Clinical notes from the prescribing healthcare provider outlining the treatment plan and rationale for using Tirzepatide.
  •  

  • Medical history demonstrating prior use and inadequate response or contraindication to at least one alternative antidiabetic agent.
  •  

  • Records of attempted lifestyle interventions.

 

Why SummaCare Might Deny Tirzepatide (Mounjaro) Coverage

 

Situations Where SummaCare May Deny Tirzepatide (Mounjaro) Coverage

 

  • The medication is prescribed for off-label use that is not approved under SummaCare's policy guidelines.
  •  

  • The patient does not meet the medical necessity criteria as defined by SummaCare, such as lacking a confirmed diagnosis that necessitates Tirzepatide (Mounjaro).
  •  

  • There is insufficient documentation or incomplete medical records provided to justify the need for Tirzepatide (Mounjaro).
  •  

  • The prescribed use does not align with current clinical guidelines or lacks sufficient evidence of effectiveness for the specific condition being treated.
  •  

  • The patient has not completed a prerequisite trial and failure of other more cost-effective or first-line therapies as per SummaCare's step therapy requirements.
  •  

  • Tirzepatide (Mounjaro) is requested within a period deemed too short after initial treatment, suggesting inappropriate use according to SummaCare's coverage terms.
  •  

  • There is an availability of alternative treatment options that are covered under the SummaCare formulary that have not been tried or have not failed.
  •  

  • The provider administering or prescribing Tirzepatide (Mounjaro) is out-of-network and does not meet the exceptions outlined in SummaCare's out-of-network coverage policy.
  •  

 

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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 SummaCare

 

Determine Eligibility for Tirzepatide Coverage

 

  • Consult SummaCare’s formulary to see if Tirzepatide (Mounjaro) is included. This helps understand the specific requirements and coverage details.
  • Review your specific plan benefits to verify if there are any additional criteria or conditions for coverage.
  • Check if there are any prior authorization requirements before obtaining the medication.

 

Consult Your Healthcare Provider

 

  • Discuss with your healthcare provider about the necessity of Tirzepatide for your condition.
  • Have your healthcare provider provide necessary documentation or explanation to support the use of Tirzepatide for you.
  • Ensure your provider is aware of any specific details required by SummaCare for coverage.

 

Contact SummaCare

 

  • Reach out to SummaCare customer service via their contact number provided on your insurance card.
  • Discuss Tirzepatide (Mounjaro) specifically, and inquire about any additional steps needed for coverage approval.
  • Ask about any forms or documentation needed from both your end and the healthcare provider to support the request.

 

Submit Prior Authorization, If Necessary

 

  • Complete any required prior authorization forms, which might often need input from your healthcare provider.
  • Submit the completed forms along with any required medical documentation or justifications.
  • Follow up with both SummaCare and your healthcare provider to ensure the prior authorization request is processed in a timely manner.

 

Review Approval and Fill Prescription

 

  • Upon receiving approval, review any specific instructions regarding co-pays or pharmacy networks where you can fill your prescription.
  • Visit an in-network pharmacy or use the specified pharmacy service as advised by SummaCare.
  • Fill your prescription for Tirzepatide and adhere to your prescribed treatment plan.

 

Appeal If Denied Coverage

 

  • If coverage is denied, request a detailed explanation for the decision from SummaCare.
  • Work with your healthcare provider to prepare additional documentation or justification to support your appeal.
  • Submit the appeal following SummaCare's specified processes, and keep track of any deadlines or requirements.

 

Regularly Review Insurance Plan

 

  • Annually review your SummaCare plan during the open enrollment period to ensure it continues to meet your medical needs, particularly regarding medications like Tirzepatide.
  • Consider changes or alternatives if your current plan’s coverage changes or if it no longer offers the support you need for your medications.

 

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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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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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