Does Tufts Health Plan Cover Lyrica

Explore Lyrica coverage by Tufts Health Plan, reasons for denial, steps to secure approval, cost without insurance, and FAQs.
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Coverage Criteria for Lyrica under Tufts Health Plan

 

  • Tufts Health Plan typically covers Lyrica when prescribed for FDA-approved indications such as neuropathic pain, fibromyalgia, and epilepsy.
  •  

  • Pre-authorization may be required to determine medical necessity based on the patient's specific condition and treatment history.
  •  

  • Documentation from a healthcare provider, supporting the need for Lyrica over alternative treatments, might be necessary.
  •  

  • Patients may need to try and fail cheaper generic medications before Lyrica coverage is approved. This is known as step therapy.

 

General Rules for Coverage

 

  • Coverage may vary depending on the specific Tufts Health Plan policy and member benefits.
  •  

  • Patients should review their plan’s formulary to confirm whether Lyrica is a covered drug and to what extent copayments or coinsurance may apply.
  •  

  • It is recommended to consult with Tufts Health Plan or a healthcare provider to ensure all required criteria and documentation are met for coverage approval.

 

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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 Lyrica Coverage with Tufts Health Plan

 

Review Your Coverage Plan

 

  • Begin by reviewing your specific Tufts Health Plan. Check if Lyrica (pregabalin) is included in your plan’s formulary, which is a list of covered medications.
  •  

  • Understand any specific conditions or tiers for drug coverage, such as whether Lyrica requires prior authorization or is categorized under a specific co-pay tier.

 

Consult with Your Doctor

 

  • Have a detailed discussion with your healthcare provider to confirm the necessity of Lyrica for your treatment plan. A doctor's prescription will be necessary to proceed.
  •  

  • Ask your doctor to provide any necessary documentation that supports the medical necessity of Lyrica, which may strengthen your case if prior authorization is required.

 

Check for Prior Authorization

 

  • Determine if prior authorization is required. This information can often be found in your benefits details or by contacting Tufts Health Plan directly.
  •  

  • If prior authorization is necessary, your healthcare provider will need to submit a request to Tufts Health Plan on your behalf.

 

Contact Tufts Health Plan Customer Service

 

  • Reach out to Tufts Health Plan’s member services for guidance on the process and to confirm which benefits specifically relate to Lyrica medication.
  •  

  • Inquire about the documentation needed and the timeline for any required authorizations.

 

Submit Claims and Documentation

 

  • If required, assist your provider in submitting a claim for Lyrica. Include all necessary information, such as the prescription, provider notes, and any justification for the medication.
  •  

  • Ensure that all paperwork is complete and submitted according to Tufts Health Plan requirements to avoid delays.

 

Follow-Up on Authorization or Claims

 

  • Keep track of the authorization or claims process by following up with both Tufts Health Plan and your healthcare provider to ensure that everything is progressing smoothly.
  •  

  • Address any issues or requests for additional information promptly to prevent any interruptions in medication access.

 

Explore Assistance Programs If Needed

 

  • If issues with coverage persist, consider exploring drug assistance programs or manufacturers’ discounts for Lyrica.
  •  

  • Discuss alternative medications with your healthcare provider if coverage for Lyrica is not possible. Some alternatives might be more readily covered under your plan.

 

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FAQs

Does Tufts Health Plan Cover Lyrica

Explore Lyrica coverage by Tufts Health Plan, reasons for denial, steps to secure approval, cost without insurance, and FAQs.
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Is Lyrica Covered by Tufts Health Plan

 

Coverage Criteria for Lyrica under Tufts Health Plan

 

  • Tufts Health Plan typically covers Lyrica when prescribed for FDA-approved indications such as neuropathic pain, fibromyalgia, and epilepsy.
  •  

  • Pre-authorization may be required to determine medical necessity based on the patient's specific condition and treatment history.
  •  

  • Documentation from a healthcare provider, supporting the need for Lyrica over alternative treatments, might be necessary.
  •  

  • Patients may need to try and fail cheaper generic medications before Lyrica coverage is approved. This is known as step therapy.

 

General Rules for Coverage

 

  • Coverage may vary depending on the specific Tufts Health Plan policy and member benefits.
  •  

  • Patients should review their plan’s formulary to confirm whether Lyrica is a covered drug and to what extent copayments or coinsurance may apply.
  •  

  • It is recommended to consult with Tufts Health Plan or a healthcare provider to ensure all required criteria and documentation are met for coverage approval.

 

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Tufts Health Plan's Approved Criteria for Lyrica Coverage

 

Criteria for Lyrica Coverage by Tufts Health Plan

 

  • **Diagnosis of Neuropathic Pain**: The patient must have a documented diagnosis of neuropathic pain associated with diabetic peripheral neuropathy or post-herpetic neuralgia. Medical records should show a history of neuropathic pain symptoms that correlate with exam findings or diagnostic testing.
  •  

  • **Fibromyalgia**: Coverage is available for patients diagnosed with fibromyalgia. Documentation from a healthcare provider should confirm the diagnosis according to established fibromyalgia criteria, typically involving widespread pain and the presence of tender points.
  •  

  • **Partial Onset Seizures**: Patients with epilepsy who have been diagnosed with partial onset seizures may receive coverage. There must be records indicating an epilepsy diagnosis consistent with partial onset seizures and an inadequate response to standard antiepileptic drugs.
  •  

  • **Generalized Anxiety Disorder (GAD)**: In specific clinical scenarios, coverage for Lyrica may be provided for patients suffering from generalized anxiety disorder, especially if they have not responded adequately to traditional treatment options. Clinical notes should illustrate the condition and previous treatment attempts.
  •  

  • **Treatment-Resistant Depression**: Individuals with treatment-resistant depression may qualify, provided there is substantial documentation of previous antidepressant treatments over an extended period, demonstrating their ineffectiveness.
  •  

  • **Approval Based on Specialist Consultation**: It is often required that a specialist, such as a neurologist, rheumatologist, or psychiatrist, has evaluated the patient and recommended Lyrica as a treatment option. Formal notes from the specialist should be included in the submission.
  •  

  • **Demonstrated Need**: The healthcare provider must demonstrate the patient's need for Lyrica as part of a comprehensive treatment plan. This involves documenting any adverse effects or inadequate relief from prior medication trials.
  •  

  • **Duration of Therapy**: Initial approval may be limited to a specific duration, often 3 to 6 months, with continuation of therapy contingent upon documented improvement in symptoms as assessed by the prescribing clinician.

 

Why Tufts Health Plan Might Deny Lyrica Coverage

 

Reasons for Denial of Lyrica Coverage

 

  • Lyrica is not covered if it is used for conditions that are not FDA-approved or considered off-label.
  •  

  • The medication may be denied if there is insufficient clinical evidence supporting its use for the requested condition.
  •  

  • Coverage may be declined if Lyrica is being used concurrently with other medications that do not align with approved combinations or reflect misuse.
  •  

  • Tufts Health Plan might deny Lyrica if the requirements for prior authorization are not met, such as providing necessary documentation or trying alternative therapies first.
  •  

  • If the prescription is not filled through participating pharmacies or providers, this could lead to coverage denial.
  •  

  • Lyrica may not be covered if there are restrictions based on the plan's formulary, which could include preference for more cost-effective alternatives.
  •  

 

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How Much Does Lyrica Cost without Insurance?

 

Cost of Lyrica Without Insurance

 

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

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

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

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

 

Our team is here to help!

Dr. Neeta Ogden, MD

Curex is poised to revolutionize the way allergies are treated in America, expanding access to clinical care and treatments that can meaningfully improve patients quality of life.

Dr. Ravi Patel, VP Telemedicine

At Curex, our mission is to help people improve their health and quality of life by understanding their allergies and treating them at their source.We provide more than individualized prescription treatments; we provide individualized care.

Jill Hamburg, PA - C

Immunotherapy made simple.  We enable patients to receive personalized allergy care on their own time. No more waiting rooms.

Dr. Chet Tharpe, Medical Director

Curex has set the standard for the virtual allergy experience. From the comfort of their home, patients nationwide are able to receive a personalized treatment plan from an experienced clinician, aimed at treating the source of their allergies, not just the symptoms.

Kayla Mardaga, NP

Curex offers convenient at-home allergy testing options. Our goal is to determine if a patient would benefit from immunotherapy and then customize a treatment plan that can reduce both the symptoms and the reliance on allergy medications.

How to Get Lyrica Coverage with Tufts Health Plan

 

Review Your Coverage Plan

 

  • Begin by reviewing your specific Tufts Health Plan. Check if Lyrica (pregabalin) is included in your plan’s formulary, which is a list of covered medications.
  •  

  • Understand any specific conditions or tiers for drug coverage, such as whether Lyrica requires prior authorization or is categorized under a specific co-pay tier.

 

Consult with Your Doctor

 

  • Have a detailed discussion with your healthcare provider to confirm the necessity of Lyrica for your treatment plan. A doctor's prescription will be necessary to proceed.
  •  

  • Ask your doctor to provide any necessary documentation that supports the medical necessity of Lyrica, which may strengthen your case if prior authorization is required.

 

Check for Prior Authorization

 

  • Determine if prior authorization is required. This information can often be found in your benefits details or by contacting Tufts Health Plan directly.
  •  

  • If prior authorization is necessary, your healthcare provider will need to submit a request to Tufts Health Plan on your behalf.

 

Contact Tufts Health Plan Customer Service

 

  • Reach out to Tufts Health Plan’s member services for guidance on the process and to confirm which benefits specifically relate to Lyrica medication.
  •  

  • Inquire about the documentation needed and the timeline for any required authorizations.

 

Submit Claims and Documentation

 

  • If required, assist your provider in submitting a claim for Lyrica. Include all necessary information, such as the prescription, provider notes, and any justification for the medication.
  •  

  • Ensure that all paperwork is complete and submitted according to Tufts Health Plan requirements to avoid delays.

 

Follow-Up on Authorization or Claims

 

  • Keep track of the authorization or claims process by following up with both Tufts Health Plan and your healthcare provider to ensure that everything is progressing smoothly.
  •  

  • Address any issues or requests for additional information promptly to prevent any interruptions in medication access.

 

Explore Assistance Programs If Needed

 

  • If issues with coverage persist, consider exploring drug assistance programs or manufacturers’ discounts for Lyrica.
  •  

  • Discuss alternative medications with your healthcare provider if coverage for Lyrica is not possible. Some alternatives might be more readily covered under your plan.

 

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Lyrica FAQ

What are the common side effects of Lyrica?

 

Common Side Effects of Lyrica

 

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

 

Is Lyrica the same as gabapentin?

 

Differences Between Lyrica and Gabapentin

 

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

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

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

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

 

Can Lyrica help with anxiety?

 

Understanding Lyrica and Anxiety

 

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

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

 

Mechanism and Effectiveness

 

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

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

 

Considerations and Side Effects

 

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

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

 

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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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