Does Tufts Health Plan Cover Emgality

Explore Emgality coverage with Tufts Health Plan, reasons for denial, costs without insurance, and FAQs. Learn how to secure coverage effectively.
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“Curex is changing the landscape of allergies in 2024”
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Coverage for Emgality under Tufts Health Plan

 

  • Tufts Health Plan may cover Emgality for patients with a diagnosed migraine and for those who have tried and failed other preventative treatments.
  •  

  • Authorization is typically required prior to coverage approval. A healthcare provider must submit a request demonstrating medical necessity.
  •  

  • Patients often need to meet specific criteria, including documentation of prior migraine treatments and their outcomes, along with the frequency and severity of migraine episodes.
  •  

  • Coverage might differ based on the specific plan type, so it is essential to confirm the benefits and requirements directly with Tufts Health Plan.
  •  

  • Policies can change, so it is advisable to regularly review the latest coverage details or consult with the provider's customer service for the most accurate information.

 

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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 Emgality Coverage with Tufts Health Plan

 

Verify Coverage with Tufts Health Plan

 

  • Contact Tufts Health Plan customer service to confirm whether Emgality is included in your specific policy's drug formulary.
  •  

  • Visit the Tufts Health Plan member portal and log in to access your benefits information. Look under the pharmacy or prescription drug benefits section for details on covered medications.

 

Consult with Your Healthcare Provider

 

  • Discuss your condition and Emgality treatment with your healthcare provider. Ensure they provide a diagnosis that aligns with Tufts Health Plan's criteria for coverage.
  •  

  • Ask your provider about alternative treatments covered by your plan if Emgality is not included, and get documentation regarding why Emgality is the best choice for your condition.

 

Obtain Prior Authorization

 

  • Request that your healthcare provider submits a prior authorization request to Tufts Health Plan. This will often require providing medical necessity documentation supporting the use of Emgality.
  •  

  • Ensure your healthcare provider includes any required forms, which can be found on the Tufts Health Plan website under the provider resources section, and complete all patient-specific information needed.

 

File an Appeal if Initial Request is Denied

 

  • If your prior authorization is denied, review the denial letter carefully to understand the reason for denial. It usually contains the reasons for the decision and instructions for how to appeal.
  •  

  • Work with your healthcare provider to gather additional documentation and a detailed explanation of the necessity of Emgality for your specific health needs.
  •  

  • Submit an appeal to Tufts Health Plan following the guidelines provided in your denial letter. Make sure to include all supporting documents that were not part of the initial request.

 

Explore Savings Programs

 

  • If challenges persist, explore pharmaceutical assistance programs or savings cards offered by the manufacturer of Emgality, which can reduce out-of-pocket costs.
  •  

  • Check if Tufts Health Plan offers any special assistance or discount programs that could help offset the costs of Emgality if not covered by the insurance.

 

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Does Tufts Health Plan Cover Emgality

Explore Emgality coverage with Tufts Health Plan, reasons for denial, costs without insurance, and FAQs. Learn how to secure coverage effectively.
Curex allergy drops unboxing

Is Emgality Covered by Tufts Health Plan

 

Coverage for Emgality under Tufts Health Plan

 

  • Tufts Health Plan may cover Emgality for patients with a diagnosed migraine and for those who have tried and failed other preventative treatments.
  •  

  • Authorization is typically required prior to coverage approval. A healthcare provider must submit a request demonstrating medical necessity.
  •  

  • Patients often need to meet specific criteria, including documentation of prior migraine treatments and their outcomes, along with the frequency and severity of migraine episodes.
  •  

  • Coverage might differ based on the specific plan type, so it is essential to confirm the benefits and requirements directly with Tufts Health Plan.
  •  

  • Policies can change, so it is advisable to regularly review the latest coverage details or consult with the provider's customer service for the most accurate information.

 

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Start with Curex

Tufts Health Plan's Approved Criteria for Emgality Coverage

 

Criteria for Emgality Coverage

 

  • **Diagnosis Confirmation:** Patients must have a confirmed diagnosis of migraine or cluster headache by a healthcare provider for coverage consideration.
  •  

  • **Chronic Migraine:** Patients with chronic migraine should have a history of experiencing migraines on 15 or more days per month for at least three months.
  •  

  • **Episodic Migraine:** For those with episodic migraines, patients should have a history of experiencing migraines on 4 to 14 days per month for at least three months.
  •  

  • **Prior Treatment Failure:** Evidence of failure, intolerance, or contraindication to at least two different classes of preventive migraine medications such as beta-blockers, anticonvulsants, or antidepressants is required.
  •  

  • **Specialty Prescription:** Emgality must be prescribed by a neurologist or headache specialist to ensure proper patient evaluation and monitoring.
  •  

  • **Age Requirement:** Patients should be 18 years of age or older to qualify for Emgality coverage under Tufts Health Plan.
  •  

  • **Treatment Duration:** Initial approval for coverage is for 12 months, with subsequent renewals requiring documentation of a positive response to therapy.
  •  

  • **Combination Therapy Guidelines:** Emgality can be used in combination with other preventive treatments only if medically necessary and justified by a healthcare provider.

 

Why Tufts Health Plan Might Deny Emgality Coverage

 

Emgality Coverage Denial Criteria

 

  • Patient does not meet the diagnosis requirement for chronic or episodic migraine as classified by ICD diagnosis codes according to Tufts Health Plan policies.
  •  

  • Lack of documentation detailing an inadequate response, intolerance, or contraindication to prior migraine treatments necessary for Emgality approval.
  •  

  • Request for Emgality exceeds the quantity limits or dosage amounts approved by Tufts Health Plan without proper justification or prior authorization.
  •  

  • Emgality is prescribed for conditions other than those specified in Tufts Health Plan’s covered indications, such as use for non-migraine related conditions.
  •  

  • Failure to comply with step therapy requirements, which mandate attempting specific alternative therapies before coverage of Emgality is approved.
  •  

  • Submission of an incomplete or missing prior authorization form, leading to automatic denial due to insufficient information.
  •  

  • The prescribed use of Emgality does not align with FDA-approved indications, and no justification for off-label use is provided or approved by Tufts Health Plan.

 

Together with our partners we have changed the lives of over 300,000 patients.

How Much Does Emgality Cost without Insurance?

 

Approximate Cost of Emgality Without Insurance

 

  • The price of Emgality (galcanezumab-gnlm) for an individual who is paying out-of-pocket can vary widely. On average, the cost for a one-month supply of Emgality, which is typically one syringe or auto-injector, is approximately $600 to $700.
  •  

  • Prices may differ based on the pharmacy and location. It's advisable to compare prices from different pharmacies, as there can be significant variation.
  •  

  • Many pharmaceutical companies, including the makers of Emgality, offer savings programs or patient assistance options for those who might struggle with the full cost of the medication. These programs can sometimes significantly reduce the out-of-pocket expenses for eligible patients.
  •  

  • In addition, discount cards or coupons from third-party services might be available that can reduce the retail price. However, always verify the legitimacy and terms of such offers.

 

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 Emgality Coverage with Tufts Health Plan

 

Verify Coverage with Tufts Health Plan

 

  • Contact Tufts Health Plan customer service to confirm whether Emgality is included in your specific policy's drug formulary.
  •  

  • Visit the Tufts Health Plan member portal and log in to access your benefits information. Look under the pharmacy or prescription drug benefits section for details on covered medications.

 

Consult with Your Healthcare Provider

 

  • Discuss your condition and Emgality treatment with your healthcare provider. Ensure they provide a diagnosis that aligns with Tufts Health Plan's criteria for coverage.
  •  

  • Ask your provider about alternative treatments covered by your plan if Emgality is not included, and get documentation regarding why Emgality is the best choice for your condition.

 

Obtain Prior Authorization

 

  • Request that your healthcare provider submits a prior authorization request to Tufts Health Plan. This will often require providing medical necessity documentation supporting the use of Emgality.
  •  

  • Ensure your healthcare provider includes any required forms, which can be found on the Tufts Health Plan website under the provider resources section, and complete all patient-specific information needed.

 

File an Appeal if Initial Request is Denied

 

  • If your prior authorization is denied, review the denial letter carefully to understand the reason for denial. It usually contains the reasons for the decision and instructions for how to appeal.
  •  

  • Work with your healthcare provider to gather additional documentation and a detailed explanation of the necessity of Emgality for your specific health needs.
  •  

  • Submit an appeal to Tufts Health Plan following the guidelines provided in your denial letter. Make sure to include all supporting documents that were not part of the initial request.

 

Explore Savings Programs

 

  • If challenges persist, explore pharmaceutical assistance programs or savings cards offered by the manufacturer of Emgality, which can reduce out-of-pocket costs.
  •  

  • Check if Tufts Health Plan offers any special assistance or discount programs that could help offset the costs of Emgality if not covered by the insurance.

 

Premium Medication you can trust

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.

Emgality FAQ

1. What are the common side effects of Emgality?

 

Common Side Effects of Emgality

 

  • Injection site reactions: including pain, redness, and itching at the injection site.
  •  

  • Constipation: a relatively frequent digestive side effect experienced by some patients.
  •  

  • Hypersensitivity reactions: such as rash, itching, or swelling in some individuals.
  •  

  • Respiratory effects: includes symptoms like cough or shortness of breath.
  •  

  • Fatigue: feelings of tiredness or lethargy reported by a number of users.
  •  

  • Difficulty sleeping: some patients may experience insomnia or sleep disturbances.

 

Consult Healthcare Provider

 

  • If side effects are severe or persistent, it is crucial to consult with a healthcare provider.

 

2. How long does it take for Emgality to start working?

 

How Emgality Works

 

  • Emgality is a monoclonal antibody that targets CGRP, a protein linked to migraine.
  •  

  • It's used for migraine prevention and treatment of cluster headaches.

 

Timeline for Effectiveness

 

  • Some patients report migraine reduction within 1 week of initial injection.
  •  

  • Maximum benefits typically observed after 2-3 months of consistent use.
  •  

  • Individual response varies; some might experience quicker relief than others.

 

Factors Influencing Effectiveness

 

  • Variability in individual biology and metabolism affects onset of relief.
  •  

  • Concurrent medications and overall health may also play a role.

 

Considerations

 

  • Consult with your healthcare provider for tailored advice based on your health profile.
  •  

  • Be consistent with your dosing schedule for optimal results.

 

3. Can Emgality be used for both prevention and treatment of migraines?

 

Usage of Emgality

 

  • Emgality is primarily approved for use as a preventive treatment for migraine. It is designed to reduce the frequency of migraine headaches in adults.
  •  

  • Emgality works by targeting and blocking the calcitonin gene-related peptide (CGRP), a molecule involved in migraine attacks.

 

Not for Acute Treatment

 

  • Emgality is not used for the acute treatment of migraine attacks once they've started. Other medications are typically prescribed for immediate relief.
  •  

  • Consult a healthcare provider for recommendations on acute migraine management options.

 

Have questions left?

Get a personalized online consultation with a doctor at Curex

Curex is one of America’s largest telehealth providers

Together with our partners we have changed the lives of over 300,000 patients. Here’s what some of them have to say:

“Curex has performed beyond my expectations. I am feeling tremendously better and look forward to continuing the treatment.”
Becky D.
"If I could give 6 stars, I would. BEST... BEST… BEST… service.”
Ferdian K.
“The Curex staff has been professional, efficient, and really focused on my individual needs.”
Ana C.

Start your
journey now

Everything you need is included:

Online consultation

Your prescription

Premium medication

Overnight shipping

Ongoing support

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. 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?

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.

Can you prescribe Ozempic®* or Wegovy®*?

Our providers focus on personalized medications and dosages that aren’t commercially available at your local pharmacy. We don’t prescribe Ozempic®* or Wegovy®.* We may prescribe treatments containing compounded semaglutide or tirzepatide. 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.

Does Tufts Health Plan Cover Emgality

Explore Emgality coverage with Tufts Health Plan, reasons for denial, costs without insurance, and FAQs. Learn how to secure coverage effectively.
Curex allergy drops unboxing

Does Tufts Health Plan Cover Emgality

 

Coverage for Emgality under Tufts Health Plan

 

  • Tufts Health Plan may cover Emgality for patients with a diagnosed migraine and for those who have tried and failed other preventative treatments.
  •  

  • Authorization is typically required prior to coverage approval. A healthcare provider must submit a request demonstrating medical necessity.
  •  

  • Patients often need to meet specific criteria, including documentation of prior migraine treatments and their outcomes, along with the frequency and severity of migraine episodes.
  •  

  • Coverage might differ based on the specific plan type, so it is essential to confirm the benefits and requirements directly with Tufts Health Plan.
  •  

  • Policies can change, so it is advisable to regularly review the latest coverage details or consult with the provider's customer service for the most accurate information.

 

A weight management program tailored to you

Start with Curex

Why Tufts Health Plan Might Deny Emgality Coverage

 

Criteria for Emgality Coverage

 

  • **Diagnosis Confirmation:** Patients must have a confirmed diagnosis of migraine or cluster headache by a healthcare provider for coverage consideration.
  •  

  • **Chronic Migraine:** Patients with chronic migraine should have a history of experiencing migraines on 15 or more days per month for at least three months.
  •  

  • **Episodic Migraine:** For those with episodic migraines, patients should have a history of experiencing migraines on 4 to 14 days per month for at least three months.
  •  

  • **Prior Treatment Failure:** Evidence of failure, intolerance, or contraindication to at least two different classes of preventive migraine medications such as beta-blockers, anticonvulsants, or antidepressants is required.
  •  

  • **Specialty Prescription:** Emgality must be prescribed by a neurologist or headache specialist to ensure proper patient evaluation and monitoring.
  •  

  • **Age Requirement:** Patients should be 18 years of age or older to qualify for Emgality coverage under Tufts Health Plan.
  •  

  • **Treatment Duration:** Initial approval for coverage is for 12 months, with subsequent renewals requiring documentation of a positive response to therapy.
  •  

  • **Combination Therapy Guidelines:** Emgality can be used in combination with other preventive treatments only if medically necessary and justified by a healthcare provider.

 

Together with our partners we have changed the lives of over 300,000 patients.

Emgality FAQ

 

Emgality Coverage Denial Criteria

 

  • Patient does not meet the diagnosis requirement for chronic or episodic migraine as classified by ICD diagnosis codes according to Tufts Health Plan policies.
  •  

  • Lack of documentation detailing an inadequate response, intolerance, or contraindication to prior migraine treatments necessary for Emgality approval.
  •  

  • Request for Emgality exceeds the quantity limits or dosage amounts approved by Tufts Health Plan without proper justification or prior authorization.
  •  

  • Emgality is prescribed for conditions other than those specified in Tufts Health Plan’s covered indications, such as use for non-migraine related conditions.
  •  

  • Failure to comply with step therapy requirements, which mandate attempting specific alternative therapies before coverage of Emgality is approved.
  •  

  • Submission of an incomplete or missing prior authorization form, leading to automatic denial due to insufficient information.
  •  

  • The prescribed use of Emgality does not align with FDA-approved indications, and no justification for off-label use is provided or approved by Tufts Health Plan.

 

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 Much Does Emgality Cost without Insurance?

 

Approximate Cost of Emgality Without Insurance

 

  • The price of Emgality (galcanezumab-gnlm) for an individual who is paying out-of-pocket can vary widely. On average, the cost for a one-month supply of Emgality, which is typically one syringe or auto-injector, is approximately $600 to $700.
  •  

  • Prices may differ based on the pharmacy and location. It's advisable to compare prices from different pharmacies, as there can be significant variation.
  •  

  • Many pharmaceutical companies, including the makers of Emgality, offer savings programs or patient assistance options for those who might struggle with the full cost of the medication. These programs can sometimes significantly reduce the out-of-pocket expenses for eligible patients.
  •  

  • In addition, discount cards or coupons from third-party services might be available that can reduce the retail price. However, always verify the legitimacy and terms of such offers.

 

Premium Medication you can trust

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.

Curex is one of America’s largest telehealth providers

Together with our partners we have changed the lives of over 300,000 patients. Here’s what some of them have to say:

“Curex has performed beyond my expectations. I am feeling tremendously better and look forward to continuing the treatment.”
Becky D.
"If I could give 6 stars, I would. BEST... BEST… BEST… service.”
Ferdian K.
“The Curex staff has been professional, efficient, and really focused on my individual needs.”
Ana C.

Start your
journey now

Everything you need is included:

Online consultation

Your prescription

Premium medication

Overnight shipping

Ongoing support

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.