Does UPMC Health Plan Cover Semaglutide (Wegovy)

Explore UPMC coverage for Semaglutide (Wegovy), reasons for denial, costs without insurance, and FAQs to ensure you get the best care possible.
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Does UPMC Health Plan Cover Semaglutide (Wegovy)?

 

  • UPMC Health Plan may cover Semaglutide (Wegovy) for weight management based on medical necessity.
  •  

  • Coverage is generally provided for patients with a body mass index (BMI) of 30 or higher, or 27 with weight-related comorbidities like diabetes or hypertension.
  •  

  • Prior authorization may be required. This involves a healthcare provider submitting documentation supporting the need for Wegovy, including previous weight loss attempts.
  •  

  • Patients should have a history of an unsuccessful weight management program, indicating that other treatments did not lead to significant results.
  •  

  • Plan members should consult their policy documents or contact UPMC Customer Service to confirm coverage details and any out-of-pocket costs.

 

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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.

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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 Semaglutide (Wegovy) Coverage with UPMC Health Plan

 

Initial Consultation with Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss your eligibility for Semaglutide (Wegovy). Ensure they are aware of your medical history and weight management goals.
  •  

  • Obtain a prescription from your healthcare provider if they determine that Wegovy is appropriate for you based on the UPMC Health Plan guidelines.

 

Review UPMC Health Plan Coverage Policies

 

  • Visit the UPMC Health Plan website to review specific coverage policies for weight management medications, including Semaglutide (Wegovy).
  •  

  • Check any requirements for prior authorization or step therapy, which might involve trying a different medication first before Wegovy is covered.

 

Contact UPMC Health Member Services

 

  • Call the UPMC Health Plan Member Services using the phone number on your insurance card. Inquire about your specific plan’s coverage for Semaglutide (Wegovy).
  •  

  • Ask if your plan requires prior authorization and what documents are needed for submission.

 

Submit Prior Authorization if Required

 

  • Work with your healthcare provider to complete any necessary forms for prior authorization. This often includes explaining your medical necessity for the medication.
  •  

  • Ensure that all required documentation, including your prescription and any supporting test results, are submitted to UPMC Health Plan.

 

Follow Up on Authorization Requests

 

  • Regularly check the status of your prior authorization request by contacting UPMC Health Plan. Be proactive to ensure there are no delays in processing.
  •  

  • Address any additional requests for information promptly to expedite the approval process.

 

Understand Your Copay or Cost Sharing

 

  • Once approved, review your plan’s copay or coinsurance details for Semaglutide (Wegovy) to understand your out-of-pocket costs.
  •  

  • Consider using UPMC’s cost estimator tools online for precise costs based on pharmacy location and dosage.

 

Fill Your Prescription

 

  • Fill your prescription at a participating pharmacy. Ensure the pharmacy has the medication in stock and understands the UPMC insurance coverage terms.
  •  

  • Provide them with any necessary details from the prior authorization approval, if applicable.

 

Review Your Coverage Annually

 

  • Insurance plan coverages can change annually. Review your benefits every year during the open enrollment period to confirm continued coverage for Semaglutide (Wegovy).
  •  

  • Contact UPMC Health Plan to discuss any changes and reassess your needs or alternative options if necessary.

 

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FAQs

Does UPMC Health Plan Cover Semaglutide (Wegovy)

Explore UPMC coverage for Semaglutide (Wegovy), reasons for denial, costs without insurance, and FAQs to ensure you get the best care possible.
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Is Semaglutide (Wegovy) Covered by UPMC Health Plan

 

Does UPMC Health Plan Cover Semaglutide (Wegovy)?

 

  • UPMC Health Plan may cover Semaglutide (Wegovy) for weight management based on medical necessity.
  •  

  • Coverage is generally provided for patients with a body mass index (BMI) of 30 or higher, or 27 with weight-related comorbidities like diabetes or hypertension.
  •  

  • Prior authorization may be required. This involves a healthcare provider submitting documentation supporting the need for Wegovy, including previous weight loss attempts.
  •  

  • Patients should have a history of an unsuccessful weight management program, indicating that other treatments did not lead to significant results.
  •  

  • Plan members should consult their policy documents or contact UPMC Customer Service to confirm coverage details and any out-of-pocket costs.

 

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UPMC Health Plan's Approved Criteria for Semaglutide (Wegovy) Coverage

 

Eligibility Criteria for Semaglutide (Wegovy) Coverage

 

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

  • **Age Requirement:** Coverage is provided to members who are 18 years of age or older.
  •  

  • **Intervention Efforts:** The member must have actively participated in a structured weight management program. Documentation of the efforts in such a program is required. This can include supervised dietary and exercise plans or weight management programs led by healthcare professionals.
  •  

  • **Medical Evaluation:** A healthcare provider must complete a thorough medical evaluation to ensure the member's suitability for treatment with Semaglutide (Wegovy). This evaluation must document the absence of contraindications and a clear benefit of usage.
  •  

  • **Prescribing Authority:** The medication must be prescribed by a healthcare provider who specializes in obesity treatment or endocrinology.
  •  

  • **Duration of Treatment:** Initial coverage is for a trial period, typically 3 to 6 months, to assess the member's response to the medication. Continued coverage may require evidence of significant weight loss or improved health metrics.
  •  

  • **Compliance with Treatment:** During the treatment period, the member must adhere to the prescribed dosage and any co-prescribed lifestyle modifications.
  •  

 

Necessary Documentation

 

  • **Medical Records:** Submission must include relevant medical history, current health conditions linked to obesity, and previous treatment attempts.
  •  

  • **Progress Reports:** Regular progress reports indicating weight loss, improvement in comorbid conditions, and adherence to therapy and lifestyle changes.
  •  

 

Provider Responsibilities

 

  • Providers must submit all documentation of clinical necessity and member progress to UPMC Health Plan as required.
  •  

  • Periodic reevaluation must be conducted to determine the continuation of therapy based on efficacy and the member's adherence to treatment protocols.
  •  

Why UPMC Health Plan Might Deny Semaglutide (Wegovy) Coverage

 

Situations for Denial of Semaglutide (Wegovy) Coverage

 

  • **Non-FDA Approved Use**: UPMC Health Plan may deny coverage if Semaglutide is prescribed for any conditions or uses not approved by the FDA.
  •  

  • **Lack of Medical Necessity**: The plan can refuse coverage if there is insufficient documentation or justification showing that the prescription of Semaglutide is medically necessary for the member.
  •  

  • **Failure to Meet BMI Requirements**: Coverage might be denied if the patient does not meet the BMI requirements established by the plan for obesity-related medications.
  •  

  • **Non-Compliance with Lifestyle Modifications**: Denial can occur if there is evidence that the patient has not complied with recommended lifestyle changes, such as diet and exercise, which are often prerequisites for drug coverage.
  •  

  • **Previous Non-response**: Coverage may not be provided if there is a documented lack of response to the medication in prior treatments, indicating ineffectiveness for the particular patient.
  •  

  • **Duplicate Therapy**: If the patient is already receiving another weight management therapy, concurrent usage of multiple therapies might lead to denial.
  •  

  • **Policy Exclusions**: UPMC Health Plan might deny coverage if the policy specifically excludes coverage for weight management drugs or treatments.

 

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How Much Does Semaglutide (Wegovy) Cost without Insurance?

 

Approximate Cost of Semaglutide (Wegovy) Without Insurance

 

  • The price of Semaglutide, commonly known as Wegovy, without insurance can be substantial, typically ranging between $1,200 and $1,400 for a supply that lasts approximately one month.
  •  

  • This medication is designed for long-term weight management, thus planning financially for sustained use is important if paying out of pocket.
  •  

  • It's important to note that prices can vary based on the pharmacy, geographic location, and available discounts or pharmacy loyalty programs.
  •  

  • Patients are encouraged to seek patient assistance programs or discounts to help mitigate costs. Some pharmaceutical manufacturers offer discount cards or assistance programs to help with the cost of prescription medications like Wegovy.

 

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 Semaglutide (Wegovy) Coverage with UPMC Health Plan

 

Initial Consultation with Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss your eligibility for Semaglutide (Wegovy). Ensure they are aware of your medical history and weight management goals.
  •  

  • Obtain a prescription from your healthcare provider if they determine that Wegovy is appropriate for you based on the UPMC Health Plan guidelines.

 

Review UPMC Health Plan Coverage Policies

 

  • Visit the UPMC Health Plan website to review specific coverage policies for weight management medications, including Semaglutide (Wegovy).
  •  

  • Check any requirements for prior authorization or step therapy, which might involve trying a different medication first before Wegovy is covered.

 

Contact UPMC Health Member Services

 

  • Call the UPMC Health Plan Member Services using the phone number on your insurance card. Inquire about your specific plan’s coverage for Semaglutide (Wegovy).
  •  

  • Ask if your plan requires prior authorization and what documents are needed for submission.

 

Submit Prior Authorization if Required

 

  • Work with your healthcare provider to complete any necessary forms for prior authorization. This often includes explaining your medical necessity for the medication.
  •  

  • Ensure that all required documentation, including your prescription and any supporting test results, are submitted to UPMC Health Plan.

 

Follow Up on Authorization Requests

 

  • Regularly check the status of your prior authorization request by contacting UPMC Health Plan. Be proactive to ensure there are no delays in processing.
  •  

  • Address any additional requests for information promptly to expedite the approval process.

 

Understand Your Copay or Cost Sharing

 

  • Once approved, review your plan’s copay or coinsurance details for Semaglutide (Wegovy) to understand your out-of-pocket costs.
  •  

  • Consider using UPMC’s cost estimator tools online for precise costs based on pharmacy location and dosage.

 

Fill Your Prescription

 

  • Fill your prescription at a participating pharmacy. Ensure the pharmacy has the medication in stock and understands the UPMC insurance coverage terms.
  •  

  • Provide them with any necessary details from the prior authorization approval, if applicable.

 

Review Your Coverage Annually

 

  • Insurance plan coverages can change annually. Review your benefits every year during the open enrollment period to confirm continued coverage for Semaglutide (Wegovy).
  •  

  • Contact UPMC Health Plan to discuss any changes and reassess your needs or alternative options if necessary.

 

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.

Semaglutide (Wegovy) FAQ

1. What are the common side effects of Semaglutide (Wegovy)?

 

Common Side Effects of Semaglutide (Wegovy)

 

  • Nausea  — Often occurs at the start of treatment and may decrease over time.
  •  

  • Vomiting  — Related to gastrointestinal upset; usually temporary.
  •  

  • Diarrhea  — Common and may vary in intensity.
  •  

  • Constipation  — It can occur alongside other digestive issues.
  •  

  • Abdominal Pain  — Includes discomfort or cramping sensation.
  •  

  • Headache  — Typically mild but can be persistent.
  •  

  • Dizziness  — May affect balance or result in vertigo-like symptoms.
  •  

  • Fatigue  — Some patients report general tiredness or lack of energy.

 

2. How much weight can I lose with Semaglutide (Wegovy)?

 

Potential Weight Loss with Semaglutide (Wegovy)

 

  • Clinical trials demonstrate that Semaglutide (Wegovy) helps individuals lose a significant amount of weight. On average, participants experienced a weight loss of about 15% of their initial body weight over 68 weeks.
  •  

  • Results vary, with some losing more and others less. Factors include adherence to medication, lifestyle changes, and individual metabolic responses.
  •  

  • Semaglutide should be part of a comprehensive weight management program, including a reduced-calorie diet and increased physical activity.
  •  

  • Consult with a healthcare professional for personalized advice and to discuss possible side effects like nausea or gastrointestinal issues.

 

3. Is Wegovy the same as Ozempic?

 

Differences Between Wegovy and Ozempic

 

  • Formulation: Both contain semaglutide, a GLP-1 receptor agonist, but are formulated for different purposes.
  •  

  • Indication: Wegovy is primarily for weight management in adults with obesity. Ozempic is prescribed for type 2 diabetes management.
  •  

  • Dosage: While both are weekly injections, Wegovy generally has higher dosing than Ozempic (up to 2.4mg vs. 1mg for Ozempic).
  •  

  • Side Effects: Common side effects overlap, including nausea, but may vary in intensity due to different dosages.

 

Conclusion

 

  • Though similar, they serve distinct medical purposes. Always consult your healthcare provider for personalized advice.

 

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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 (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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