Does Tufts Health Plan Cover Saxenda

Learn about Saxenda coverage by Tufts Health Plan, reasons for denial, tips for approval, costs without insurance, and FAQs in an insightful guide.
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Coverage Criteria for Saxenda

 

  • Tufts Health Plan may cover Saxenda for patients diagnosed with obesity or overweight conditions coupled with weight-related health issues such as type 2 diabetes, hypertension, or sleep apnea.
  •  

  • Coverage typically requires prior authorization. The prescribing healthcare provider must submit necessary documentation demonstrating medical necessity.
  •  

    Basic Eligibility Rules

     

    • Patients usually need to meet specific BMI criteria: a BMI of 30 or more, or a BMI of 27 with concurrent weight-related medical conditions.
    •  

    • Participation in a comprehensive weight management program may be required, including lifestyle interventions such as diet, exercise, and behavioral modification.
    •  

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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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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 Saxenda Coverage with Tufts Health Plan

 

Review Tufts Health Plan Policy on Saxenda

 

  • Visit the official Tufts Health Plan website to understand their specific policy on covering medications like Saxenda. Policies can vary based on your specific plan, so it's important to find information relevant to your coverage.
  •  

  • Look for details under the pharmacy or prescription drug coverage section. Tufts Health Plan may have a formulary list available online that includes Saxenda.

 

Consult with Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss the possibility of incorporating Saxenda into your treatment plan.
  •  

  • Your provider will need to provide a medical necessity letter or complete a prior authorization request, depending on the requirements of Tufts Health Plan, justifying the need for Saxenda based on your health status.

 

Contact Tufts Health Plan Member Services

 

  • Reach out to Tufts Health Plan Member Services for clarification on specific steps you need to take for Saxenda coverage. The contact information should be available on the back of your member ID card or their website.
  •  

  • Ask them to confirm the coverage details and discuss any prerequisites, such as step therapy requirements, that may need to be met before Saxenda is approved.
  •  

  • Inquire about the co-payment or any out-of-pocket costs associated with Saxenda under your current health plan.

 

Submit a Prior Authorization Request

 

  • Work with your healthcare provider to submit a prior authorization request to Tufts Health Plan for Saxenda coverage. Ensure that all necessary documentation, such as your medical history and the provider's justification for Saxenda, is included.
  •  

  • Make sure to follow any specific submission instructions outlined by Tufts Health Plan. This might include completing specific forms or submitting documents through an online portal.

 

Follow Up on Your Request

 

  • Monitor the status of your prior authorization request. This can usually be done via an online account with Tufts Health Plan or by calling Member Services.
  •  

  • If additional information is requested, respond promptly to avoid delays in the approval process.

 

Appeal If Necessary

 

  • If Saxenda coverage is denied, inquire about the appeals process. Tufts Health Plan should provide information on how to formally appeal the decision.
  •  

  • Work closely with your healthcare provider during the appeal process to provide any additional documentation or information that may be necessary to support the approval of Saxenda.

 

Explore Assistance Programs

 

  • If you're facing high costs even with coverage, consider exploring patient assistance programs or discounts provided by the manufacturer of Saxenda.
  •  

  • Your healthcare provider or a pharmacist may have information on such programs to help reduce out-of-pocket expenses.

 

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FAQs

Does Tufts Health Plan Cover Saxenda

Learn about Saxenda coverage by Tufts Health Plan, reasons for denial, tips for approval, costs without insurance, and FAQs in an insightful guide.
Curex allergy drops unboxing

Is Saxenda Covered by Tufts Health Plan

 

Coverage Criteria for Saxenda

 

  • Tufts Health Plan may cover Saxenda for patients diagnosed with obesity or overweight conditions coupled with weight-related health issues such as type 2 diabetes, hypertension, or sleep apnea.
  •  

  • Coverage typically requires prior authorization. The prescribing healthcare provider must submit necessary documentation demonstrating medical necessity.
  •  

    Basic Eligibility Rules

     

    • Patients usually need to meet specific BMI criteria: a BMI of 30 or more, or a BMI of 27 with concurrent weight-related medical conditions.
    •  

    • Participation in a comprehensive weight management program may be required, including lifestyle interventions such as diet, exercise, and behavioral modification.
    •  

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Tufts Health Plan's Approved Criteria for Saxenda Coverage

 

Criteria for Saxenda Coverage under Tufts Health Plan

 

  • The member must have a diagnosis of obesity, specifically a Body Mass Index (BMI) of 30 kg/m² or greater.
  •  

  • Alternatively, the member should have a BMI of 27 kg/m² or greater, along with at least one weight-related comorbidity. Examples of comorbidities include hypertension, type 2 diabetes, or dyslipidemia.
  •  

  • Documentation of participation in a comprehensive weight management program, which includes dietary adjustments, physical activity, and behavioral therapy, is required prior to Saxenda initiation.
  •  

  • The prescription of Saxenda should be made by or in consultation with an endocrinologist, a bariatric specialist, or another healthcare professional skilled in obesity management.
  •  

  • Proof of non-response to prior weight-loss interventions, including lifestyle modifications and previous pharmacotherapies, should be provided.
  •  

  • The member should not have any contraindications to Saxenda, such as a history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).
  •  

  • Continuing coverage criteria may require documentation of weight loss at specific intervals, typically a certain percentage at 16 weeks into treatment.

 

Why Tufts Health Plan Might Deny Saxenda Coverage

 

Criteria for Denial of Saxenda Coverage by Tufts Health Plan

 

  • Prescription for weight loss in patients without a diagnosis of obesity or overweight with weight-related comorbidities.
  •  

  • Patient has not met the required Body Mass Index (BMI) criteria as specified by Tufts Health Plan for obesity treatment.
  •  

  • Lack of documented previous unsuccessful attempts at weight loss through diet and exercise.
  •  

  • Request for Saxenda usage outside the approved dosing and duration guidelines set by the plan.
  •  

  • Absence of medical documentation supporting the necessity of Saxenda in the patient’s treatment plan.
  •  

  • Patient history of adverse reactions to Saxenda or its components not appropriately addressed.
  •  

  • Saxenda prescribed in combination with other weight-management drugs not covered or regarded as necessary by Tufts Health Plan.
  •  

  • Failure to provide required prior authorization forms or incomplete documentation during the approval process.

 

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How Much Does Saxenda Cost without Insurance?

 

Approximate Cost of Saxenda Without Insurance

 

  • Saxenda is a prescription medication used to aid in weight loss and management for patients who are overweight or have obesity-related medical problems.
  •  

  • Without insurance, the cost of Saxenda can be substantial. Prices typically range from $1,200 to $1,500 for a 30-day supply, which consists of 3 pens.
  •  

  • The exact cost can vary based on the pharmacy you visit and potential discounts or coupons you may be able to use.
  •  

  • It's important to consider the long-term cost if Saxenda is prescribed for an extended period, as the monthly expense can add up significantly over time.
  •  

  • Some pharmacies may offer loyalty programs or discounts that can slightly reduce the cost, so it's advisable to shop around or inquire about savings programs.
  •  

  • Additionally, pharmaceutical assistance programs or patient assistance programs might be available for eligible patients to help minimize out-of-pocket 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 Saxenda Coverage with Tufts Health Plan

 

Review Tufts Health Plan Policy on Saxenda

 

  • Visit the official Tufts Health Plan website to understand their specific policy on covering medications like Saxenda. Policies can vary based on your specific plan, so it's important to find information relevant to your coverage.
  •  

  • Look for details under the pharmacy or prescription drug coverage section. Tufts Health Plan may have a formulary list available online that includes Saxenda.

 

Consult with Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss the possibility of incorporating Saxenda into your treatment plan.
  •  

  • Your provider will need to provide a medical necessity letter or complete a prior authorization request, depending on the requirements of Tufts Health Plan, justifying the need for Saxenda based on your health status.

 

Contact Tufts Health Plan Member Services

 

  • Reach out to Tufts Health Plan Member Services for clarification on specific steps you need to take for Saxenda coverage. The contact information should be available on the back of your member ID card or their website.
  •  

  • Ask them to confirm the coverage details and discuss any prerequisites, such as step therapy requirements, that may need to be met before Saxenda is approved.
  •  

  • Inquire about the co-payment or any out-of-pocket costs associated with Saxenda under your current health plan.

 

Submit a Prior Authorization Request

 

  • Work with your healthcare provider to submit a prior authorization request to Tufts Health Plan for Saxenda coverage. Ensure that all necessary documentation, such as your medical history and the provider's justification for Saxenda, is included.
  •  

  • Make sure to follow any specific submission instructions outlined by Tufts Health Plan. This might include completing specific forms or submitting documents through an online portal.

 

Follow Up on Your Request

 

  • Monitor the status of your prior authorization request. This can usually be done via an online account with Tufts Health Plan or by calling Member Services.
  •  

  • If additional information is requested, respond promptly to avoid delays in the approval process.

 

Appeal If Necessary

 

  • If Saxenda coverage is denied, inquire about the appeals process. Tufts Health Plan should provide information on how to formally appeal the decision.
  •  

  • Work closely with your healthcare provider during the appeal process to provide any additional documentation or information that may be necessary to support the approval of Saxenda.

 

Explore Assistance Programs

 

  • If you're facing high costs even with coverage, consider exploring patient assistance programs or discounts provided by the manufacturer of Saxenda.
  •  

  • Your healthcare provider or a pharmacist may have information on such programs to help reduce out-of-pocket expenses.

 

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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.

Saxenda FAQ

1. How much weight can you lose with Saxenda?

 

Expected Weight Loss with Saxenda

 

  • According to clinical studies, Saxenda helps achieve significant weight loss; patients can expect to lose around 5% to 10% of their initial body weight.
  •  

  • The average weight loss in clinical trials was approximately 8%, but individual results can vary based on several factors including diet and exercise.
  •  

  • For some, weight loss may exceed 10%, while others may experience less than 5% reduction.
  •  

  • Adopt lifestyle changes alongside Saxenda, like improved diet and increased physical activity, to maximize weight loss.
  •  

 

2. What are the common side effects of Saxenda?

 

Common Side Effects of Saxenda

 

  • Nausea: This is the most frequently reported side effect, often decreasing over time as the body adjusts.
  •  

  • Diarrhea: Changes in bowel habits, including diarrhea, are possible but usually manageable.
  •  

  • Constipation: Some patients experience constipation, a common gastrointestinal effect.
  •  

  • Vomiting: Vomiting can occur, especially in the initial stages of treatment.
  •  

  • Headache: Many patients report headaches, though these often lessen as treatment progresses.
  •  

  • Dizziness: Feeling lightheaded or dizzy can accompany Saxenda use.
  •  

  • Fatigue: Tiredness or fatigue is commonly noted but tends to be temporary.
  •  

  • Injection Site Reactions: Redness or irritation at the injection site may occur.

 

3. How long does it take for Saxenda to start working?

 

How Saxenda Works

 

  • Saxenda is a GLP-1 receptor agonist, which works by decreasing appetite and caloric intake.
  •  

  • The onset of its effects can vary among individuals.

 

Timeframe for Effects

 

  • Patients may start experiencing decreased appetite within the first week of treatment.
  •  

  • Noticeable weight loss usually begins after 4-8 weeks, especially when combined with a reduced-calorie diet and increased physical activity.

 

Monitoring Progress

 

  • Regular follow-ups with your healthcare provider are essential to assess progress and adjust the dosage if necessary.
  •  

  • Adherence to lifestyle changes significantly enhances results with Saxenda.

 

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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.

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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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