Does UPMC Health Plan Cover Saxenda

Discover if UPMC Health Plan covers Saxenda, learn why it might be denied, explore cost solutions, and get answers to frequently asked questions.
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UPMC Health Plan Coverage for Saxenda

 

  • UPMC Health Plan may cover Saxenda based on specific medical necessity requirements. It is generally prescribed for individuals with a body mass index (BMI) over 30 or over 27 with obesity-related conditions.
  •  

  • Members may be required to complete prior authorization, demonstrating that Saxenda is a necessary treatment after other weight management options have been tried or considered.
  •  

  • Physician documentation supporting the use of Saxenda, including past weight management attempts, is typically needed.
  •  

  • Coverage may vary by specific plan, and members are advised to review their policy details or contact UPMC Health Plan directly for personal eligibility and coverage criteria.
  •  

  • Additional support documents, patient history, and compliance with specific guidelines may be required as part of the approval process.

 

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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 UPMC Health Plan

 

Contact UPMC Health Plan Member Services

 

  • Start by reaching out to UPMC Health Plan Member Services. You can find the contact information on the back of your insurance card or on the UPMC Health Plan website.
  •  

  • Ask for detailed information about your current policy and whether Saxenda is included in the list of covered medications.

 

Consult with Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss the medical necessity of Saxenda for your treatment.
  •  

  • Your doctor may need to provide documentation or complete forms to demonstrate that Saxenda is medically necessary for you.

 

Review Your Pharmacy Benefits

 

  • Access your pharmacy benefits information through the UPMC Health Plan portal or contact their pharmacy services team for detailed information on medication coverage.
  •  

  • Ask if Saxenda falls under any special categories or requires prior authorization.

 

Submit a Prior Authorization Request

 

  • If Saxenda requires prior authorization, work with your healthcare provider to complete and submit the necessary forms to UPMC Health Plan for approval.
  •  

  • Provide all required medical information to support the necessity of Saxenda for your health condition.

 

Follow Up on the Authorization Process

 

  • Stay in contact with UPMC Health Plan to monitor the status of your prior authorization request.
  •  

  • Ensure your healthcare provider is also updated on any communications or additional documentation requests from the health plan.

 

Appeal if Necessary

 

  • If your request for coverage is denied, ask UPMC Health Plan about the appeals process.
  •  

  • Work with your healthcare provider to collect and submit additional evidence or documentation that could support your case for Saxenda coverage.

 

Explore Patient Assistance Programs

 

  • If insurance coverage for Saxenda remains unattainable, check with the manufacturer or charitable organizations for any available patient assistance programs.
  •  

  • These programs might offer financial help or discounts for those who qualify.

 

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FAQs

Does UPMC Health Plan Cover Saxenda

Discover if UPMC Health Plan covers Saxenda, learn why it might be denied, explore cost solutions, and get answers to frequently asked questions.
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Is Saxenda Covered by UPMC Health Plan

 

UPMC Health Plan Coverage for Saxenda

 

  • UPMC Health Plan may cover Saxenda based on specific medical necessity requirements. It is generally prescribed for individuals with a body mass index (BMI) over 30 or over 27 with obesity-related conditions.
  •  

  • Members may be required to complete prior authorization, demonstrating that Saxenda is a necessary treatment after other weight management options have been tried or considered.
  •  

  • Physician documentation supporting the use of Saxenda, including past weight management attempts, is typically needed.
  •  

  • Coverage may vary by specific plan, and members are advised to review their policy details or contact UPMC Health Plan directly for personal eligibility and coverage criteria.
  •  

  • Additional support documents, patient history, and compliance with specific guidelines may be required as part of the approval process.

 

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UPMC Health Plan's Approved Criteria for Saxenda Coverage

 

Eligibility for Saxenda Coverage

 

  • Members must be 18 years of age or older to qualify for coverage of Saxenda.
  •  

  • The patient must have a Body Mass Index (BMI) of 30 kg/m² or higher, classified as obese, or a BMI of 27 kg/m² or higher with at least one weight-related comorbidity such as type 2 diabetes, hypertension, or dyslipidemia.

 

Previous Weight Management Efforts

 

  • Documentation of previous weight management efforts must be provided, indicating that the patient has attempted and failed with conventional weight loss methods like dietary changes, exercise programs, or behavior modification therapy.
  •  

  • Patients are required to participate in a structured weight management program under medical supervision to be eligible for Saxenda coverage.

 

Medical Evaluation

 

  • A comprehensive medical evaluation must be completed to ensure no contraindications for using Saxenda and to assess the risks versus benefits of introducing this medication.
  •  

  • Potential psychological issues contributing to weight gain should be identified and managed as part of a holistic weight-loss plan.

 

Prescription Requirements

 

  • Saxenda must be prescribed by a licensed healthcare provider who specializes in obesity management or a related field, ensuring that the prescribing practitioner has the requisite training and understanding of Saxenda’s use.
  •  

  • The prescription for Saxenda must include a dosing regimen consistent with the FDA-approved labeling for Saxenda.

 

Ongoing Monitoring and Continued Use

 

  • Coverage continuation is subject to regular follow-up appointments to monitor progress, side effects, and adherence to the weight management program.
  •  

  • Demonstrated success in achieving measurable weight loss results, typically defined by a specific percentage of body weight, must be documented to maintain coverage of Saxenda.

 

Why UPMC Health Plan Might Deny Saxenda Coverage

 

Saxenda Coverage Denial Criteria by UPMC Health Plan

 

  • Saxenda is not covered for non-FDA approved uses. Any off-label use of Saxenda will result in a denial of coverage.
  •  

  • The Health Plan may deny coverage if the member does not meet the specified Body Mass Index (BMI) criteria required for initiating Saxenda therapy. Typically, patients must have a BMI of 30 or greater, or a BMI of 27 or greater with at least one weight-related condition.
  •  

  • Absence of documentation proving previous attempts to lose weight using traditional methods such as dieting, exercising, and behavior therapy may lead to denial.
  •  

  • Coverage might be denied if the healthcare provider fails to provide a comprehensive medical history of the patient, including past treatments and outcomes relevant to obesity management.
  •  

  • Saxenda is not intended for individuals with a history of serious or unstable mental health conditions. Coverage may be denied if the patient's medical records reflect these issues.
  •  

  • The medication is not covered for pediatric patients, as Saxenda is approved only for adult use in weight management. Use in anyone under the age of 18 will likely result in denial of coverage.
  •  

  • UPMC Health Plan may deny coverage if Saxenda is being requested in combination with other weight loss medications, which is not the intended use per FDA guidelines.
  •  

  • Denial can occur if there is insufficient evidence of medical necessity or a lack of proper documentation supporting the need for Saxenda as part of the patient's treatment plan.

 

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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 UPMC Health Plan

 

Contact UPMC Health Plan Member Services

 

  • Start by reaching out to UPMC Health Plan Member Services. You can find the contact information on the back of your insurance card or on the UPMC Health Plan website.
  •  

  • Ask for detailed information about your current policy and whether Saxenda is included in the list of covered medications.

 

Consult with Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss the medical necessity of Saxenda for your treatment.
  •  

  • Your doctor may need to provide documentation or complete forms to demonstrate that Saxenda is medically necessary for you.

 

Review Your Pharmacy Benefits

 

  • Access your pharmacy benefits information through the UPMC Health Plan portal or contact their pharmacy services team for detailed information on medication coverage.
  •  

  • Ask if Saxenda falls under any special categories or requires prior authorization.

 

Submit a Prior Authorization Request

 

  • If Saxenda requires prior authorization, work with your healthcare provider to complete and submit the necessary forms to UPMC Health Plan for approval.
  •  

  • Provide all required medical information to support the necessity of Saxenda for your health condition.

 

Follow Up on the Authorization Process

 

  • Stay in contact with UPMC Health Plan to monitor the status of your prior authorization request.
  •  

  • Ensure your healthcare provider is also updated on any communications or additional documentation requests from the health plan.

 

Appeal if Necessary

 

  • If your request for coverage is denied, ask UPMC Health Plan about the appeals process.
  •  

  • Work with your healthcare provider to collect and submit additional evidence or documentation that could support your case for Saxenda coverage.

 

Explore Patient Assistance Programs

 

  • If insurance coverage for Saxenda remains unattainable, check with the manufacturer or charitable organizations for any available patient assistance programs.
  •  

  • These programs might offer financial help or discounts for those who qualify.

 

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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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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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