Does UPMC Health Plan Cover Xarelto

Explore UPMC Health Plan's Xarelto coverage, costs, and steps to secure approval. Learn why denials occur and get answers to common questions.
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UPMC Health Plan Coverage for Xarelto

 

  • UPMC Health Plan may cover Xarelto, a blood thinner, under its pharmacy benefits. Coverage can depend on the specific health plan you are enrolled in.
  •  

  • Typically, coverage is subject to the drug being deemed medically necessary, which usually requires a prescription from a healthcare provider.
  •  

  • Some plans may require prior authorization. This means it will be necessary to demonstrate that Xarelto is the most appropriate treatment by providing relevant medical documentation.
  •  

  • Coverage might also entail adherence to formulary guidelines, which list covered drugs, and could affect cost-sharing or copay amounts.
  •  

  • Check if Xarelto falls under preferred brand-name medicines, which may affect how much you pay out-of-pocket. Sometimes, lower-cost alternatives are suggested.

 

Steps to Ensure Coverage

 

  • Consult with your doctor to confirm that Xarelto is clinically justified in your case. Understand the possible requirements for coverage.
  •  

  • Contact UPMC Health Plan directly or consult their website to verify if your specific plan includes Xarelto and to understand any potential processes like prior authorization or formulary exceptions.
  •  

  • Stay updated on any policy changes, as coverage details can evolve frequently based on formulary updates and healthcare regulations.

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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 Xarelto Coverage with UPMC Health Plan

 

Verify Your Prescription

 

  • Make sure that your healthcare provider has prescribed Xarelto for a condition that is currently covered under your UPMC Health Plan.
  •  

  • Check the UPMC Health Plan formulary, which details drugs covered under different plan options. Ensure that Xarelto is listed under your specific plan's formulary.

 

Consult with Your Healthcare Provider

 

  • Speak to your provider about the medical necessity of Xarelto and ask them to provide any required documentation or prior authorizations needed by UPMC Health Plan.
  •  

  • Your provider might need to submit a detailed justification or complete a prior authorization form, especially if Xarelto is a second-line treatment for your condition.

 

Contact UPMC Health Plan Customer Service

 

  • Call the customer service number listed on your UPMC Health Plan card to understand the specific requirements for Xarelto coverage under your plan.
  •  

  • Ask about any potential copayments or costs associated with obtaining Xarelto under your insurance plan.

 

Submit a Prior Authorization Request

 

  • If necessary, complete any prior authorization forms. These forms often require details from your healthcare provider regarding your medical condition and the necessity of Xarelto.
  •  

  • Send the completed form and any supporting documents to UPMC Health Plan as directed, which may include using online portals, faxing, or mailing.

 

Enroll in a UPMC Health Plan Pharmacy Benefit

 

  • Ensure that you have enrolled in the pharmacy benefits program of your UPMC Health Plan, if not already done.
  •  

  • Verify if there are any networks or preferred pharmacies that provide additional savings or coverage benefits for prescriptions like Xarelto.

 

Verify Coverage Determination

 

  • Follow up with UPMC Health Plan to verify the status of your prior authorization request or any additional steps needed.
  •  

  • Once approved, confirm any remaining out-of-pocket costs and refill procedures for obtaining Xarelto.

 

Appeal if Denied

 

  • If your coverage request for Xarelto is denied, review the denial letter to understand the reasons and what further information might be needed.
  •  

  • Contact UPMC Health Plan’s appeals department to start an appeal and provide additional documentation or evidence of medical necessity, if needed.

 

Explore Assistance Programs

 

  • If you are facing high out-of-pocket costs even with coverage, explore if there are any financial assistance programs or manufacturer discounts for Xarelto that you might be eligible for.
  •  

  • UPMC Health Plan might have information on additional resources or programs to help manage medication expenses.

 

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FAQs

Does UPMC Health Plan Cover Xarelto

Explore UPMC Health Plan's Xarelto coverage, costs, and steps to secure approval. Learn why denials occur and get answers to common questions.
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Is Xarelto Covered by UPMC Health Plan

 

UPMC Health Plan Coverage for Xarelto

 

  • UPMC Health Plan may cover Xarelto, a blood thinner, under its pharmacy benefits. Coverage can depend on the specific health plan you are enrolled in.
  •  

  • Typically, coverage is subject to the drug being deemed medically necessary, which usually requires a prescription from a healthcare provider.
  •  

  • Some plans may require prior authorization. This means it will be necessary to demonstrate that Xarelto is the most appropriate treatment by providing relevant medical documentation.
  •  

  • Coverage might also entail adherence to formulary guidelines, which list covered drugs, and could affect cost-sharing or copay amounts.
  •  

  • Check if Xarelto falls under preferred brand-name medicines, which may affect how much you pay out-of-pocket. Sometimes, lower-cost alternatives are suggested.

 

Steps to Ensure Coverage

 

  • Consult with your doctor to confirm that Xarelto is clinically justified in your case. Understand the possible requirements for coverage.
  •  

  • Contact UPMC Health Plan directly or consult their website to verify if your specific plan includes Xarelto and to understand any potential processes like prior authorization or formulary exceptions.
  •  

  • Stay updated on any policy changes, as coverage details can evolve frequently based on formulary updates and healthcare regulations.

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UPMC Health Plan's Approved Criteria for Xarelto Coverage

 

UPMC Health Plan Coverage Criteria for Xarelto

 

  • **Diagnosis-Specific Indications**:
    • Xarelto is covered for patients with atrial fibrillation, deep vein thrombosis, pulmonary embolism, and for the reduction of risk of recurrence of DVT and PE.
    • Coverage is also provided for patients as a prophylactic for deep vein thrombosis in patients undergoing knee or hip replacement surgery.
  •  

  • **Age Restrictions**:
    • Patients must be adults, generally aged 18 or older, unless specified differently for particular conditions.
  •  

  • **Physician Authorization**:
    • Xarelto must be prescribed by a healthcare provider who is authorized by UPMC Health Plan.
  •  

  • **Dose and Administration**:
    • Coverage aligns with FDA-approved dosing guidelines. Patients must adhere to prescribed doses.
    • Adjustments or specific conditions required for dosing must be documented and approved by the healthcare provider.
  •  

  • **Step Therapy Requirements**:
    • For certain conditions, patient must have tried and failed other suitable medications before Xarelto will be covered, unless such medications are contraindicated.
  •  

  • **Medical History Documentation**:
    • Comprehensive medical history detailing previous therapies and outcomes may be required to validate the appropriateness of Xarelto for the patient.
  •  

  • **Compliance with Guidelines**:
    • Patients and prescribing physicians must demonstrate compliance with established clinical guidelines for anticoagulation therapy.
  •  

  • **Continued Therapy Assessment**:
    • Ongoing assessments by healthcare providers to evaluate efficacy and safety are required for continued coverage of Xarelto.
  •  

 

Why UPMC Health Plan Might Deny Xarelto Coverage

 

Conditions for Denial of Coverage for Xarelto by UPMC Health Plan

 

  • If the patient does not meet the medical necessity criteria set by UPMC, Xarelto may not be covered. This may include situations where the prescribed use does not align with approved indications.
  •  

  • The UPMC Health Plan may deny coverage if the medication is deemed experimental or investigational for the patient's condition. This includes uses not within the FDA-approved label that the health plan recognizes as standard care.
  •  

  • A prior authorization is often required for Xarelto. If the healthcare provider fails to obtain this authorization beforehand, coverage may be denied.
  •  

  • In cases where generic alternatives or other therapeutic equivalents are available and deemed appropriate, the plan might refuse to cover Xarelto, pushing for the use of lower-cost options instead.
  •  

  • Non-compliance with formulary guidelines, which may prioritize certain medications over Xarelto for cost-effectiveness, can result in denial of coverage.
  •  

  • Coverage may also be denied if the patient does not adhere to required step therapy protocols, which involve trying one or more alternative medications before approval of Xarelto.
  •  

  • Lapses in plan premiums or registration issues with the UPMC Health Plan could lead to denial of coverage for Xarelto, among other medications.
  •  

 

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How Much Does Xarelto Cost without Insurance?

 

Approximate Cost of Xarelto Without Insurance

 

  • The cost for Xarelto, a prescription anticoagulant medication, can vary depending on the dosage and quantity prescribed. On average, the cost of a 30-day supply of Xarelto 20 mg tablets, without insurance, can range from $450 to $540.
  •  

  • Prices may differ at various pharmacies, and patients might find lower prices through discount programs or pharmacy discount cards.
  •  

  • Shopping around and comparing prices at different pharmacies or checking with online retailers can sometimes yield better deals or discounts.
  •  

  • Additional savings may be available through pharmaceutical assistance programs, which are offered by the manufacturer for eligible patients who meet specific criteria.

 

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 Xarelto Coverage with UPMC Health Plan

 

Verify Your Prescription

 

  • Make sure that your healthcare provider has prescribed Xarelto for a condition that is currently covered under your UPMC Health Plan.
  •  

  • Check the UPMC Health Plan formulary, which details drugs covered under different plan options. Ensure that Xarelto is listed under your specific plan's formulary.

 

Consult with Your Healthcare Provider

 

  • Speak to your provider about the medical necessity of Xarelto and ask them to provide any required documentation or prior authorizations needed by UPMC Health Plan.
  •  

  • Your provider might need to submit a detailed justification or complete a prior authorization form, especially if Xarelto is a second-line treatment for your condition.

 

Contact UPMC Health Plan Customer Service

 

  • Call the customer service number listed on your UPMC Health Plan card to understand the specific requirements for Xarelto coverage under your plan.
  •  

  • Ask about any potential copayments or costs associated with obtaining Xarelto under your insurance plan.

 

Submit a Prior Authorization Request

 

  • If necessary, complete any prior authorization forms. These forms often require details from your healthcare provider regarding your medical condition and the necessity of Xarelto.
  •  

  • Send the completed form and any supporting documents to UPMC Health Plan as directed, which may include using online portals, faxing, or mailing.

 

Enroll in a UPMC Health Plan Pharmacy Benefit

 

  • Ensure that you have enrolled in the pharmacy benefits program of your UPMC Health Plan, if not already done.
  •  

  • Verify if there are any networks or preferred pharmacies that provide additional savings or coverage benefits for prescriptions like Xarelto.

 

Verify Coverage Determination

 

  • Follow up with UPMC Health Plan to verify the status of your prior authorization request or any additional steps needed.
  •  

  • Once approved, confirm any remaining out-of-pocket costs and refill procedures for obtaining Xarelto.

 

Appeal if Denied

 

  • If your coverage request for Xarelto is denied, review the denial letter to understand the reasons and what further information might be needed.
  •  

  • Contact UPMC Health Plan’s appeals department to start an appeal and provide additional documentation or evidence of medical necessity, if needed.

 

Explore Assistance Programs

 

  • If you are facing high out-of-pocket costs even with coverage, explore if there are any financial assistance programs or manufacturer discounts for Xarelto that you might be eligible for.
  •  

  • UPMC Health Plan might have information on additional resources or programs to help manage medication expenses.

 

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Xarelto FAQ

What are the common side effects of Xarelto?

 

Common Side Effects of Xarelto

 

  • Bleeding is the most common, including nasal, gum, or gastrointestinal bleeding. Be vigilant for any signs of unusual bleeding and seek medical attention if necessary.
  •  

  • Gastrointestinal issues such as nausea and stomach pain may occur. Taking Xarelto with food can help alleviate these symptoms.
  •  

  • Dizziness and fatigue can affect some individuals, especially when first starting the medication. Ensure you maintain hydration and rest as needed.
  •  

  • In rare cases, allergic reactions may manifest as rash or itching. If this occurs, consult your healthcare provider promptly.

 

Is Xarelto a blood thinner?

 

Is Xarelto a Blood Thinner?

 

  • **Xarelto (rivaroxaban)** is indeed a blood thinner, specifically an anticoagulant, which is crucial for preventing blood clots that can lead to conditions like stroke or deep vein thrombosis (DVT).
  •  

  • It works by inhibiting **factor Xa**, an essential component in the coagulation cascade, reducing the ability of blood to form clots.
  •  

  • As a **direct oral anticoagulant (DOAC)**, it provides several advantages over traditional blood thinners like warfarin, such as having fewer dietary restrictions and not requiring regular blood monitoring.
  •  

  • It's important to take it as prescribed by a healthcare provider, considering potential drug interactions and contraindications.

 

Can you drink alcohol while taking Xarelto?

 

Drinking Alcohol with Xarelto

 

  • Xarelto, a blood thinner, may increase bleeding risk, and alcohol can amplify this risk.
  •  

  • Both substances affect liver function, potentially impacting medication metabolism and effectiveness.
  •  

  • Consuming alcohol while on Xarelto may enhance side effects like dizziness, increasing injury risk.
  •  

  • It’s crucial to consult your healthcare provider to discuss allowable alcohol intake based on your health status and dosage.
  •  

 

General Recommendations

 

  • Moderation is key – if approved, limit alcohol consumption as per medical advice.
  •  

  • Avoid binge drinking, which drastically heightens risk of adverse reactions.
  •  

  • Inform your medical team about recreational activities involving alcohol.

 

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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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