Does Affinity Health Plan Cover Phentermine/Topiramate ER (Qsymia)

Discover if Affinity covers Phentermine/Topiramate ER, reasons for denial, tips for coverage, costs without insurance, and FAQs in this comprehensive guide.
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Qsymia Coverage with Affinity Health Plan

 

  • Affinity Health Plan may cover Phentermine/Topiramate ER (Qsymia) as part of their formulary for weight management therapies.
  •  

  • Coverage often requires prior authorization. Patients generally need to meet specific criteria, including a diagnosis of obesity or weight-related conditions such as hypertension or type 2 diabetes.
  •  

  • Prescribers typically need to provide evidence that lifestyle interventions alone were insufficient for weight loss.
  •  

  • Patients may need to demonstrate adherence to a structured weight management program while on Qsymia.
  •  

  • Review specific plan details and consult with Affinity Health Plan directly to confirm coverage specifics and required documentation.

 

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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 Phentermine/Topiramate ER (Qsymia) Coverage with Affinity Health Plan

 

Understanding Your Coverage with Affinity Health Plan

 

  • Review your plan details for prescription drug coverage related to weight management medications.
  •  

  • Contact Affinity Health Plan customer service to confirm specific coverage for Phentermine/Topiramate ER (Qsymia).

 

Consult with Your Healthcare Provider

 

  • Discuss the potential benefits and appropriateness of Phentermine/Topiramate ER (Qsymia) for your health needs.
  •  

  • Have your healthcare provider document the medical necessity for the medication. This documentation will be crucial for insurance approval.

 

Utilize the Affinity Health Plan Provider Network

 

  • Select a healthcare provider within the Affinity Health Plan network to reduce out-of-pocket costs.
  •  

  • Your in-network provider can directly handle authorizations and communications with the insurance company.

 

Complete a Prior Authorization Request

 

  • Work with your healthcare provider to complete and submit a prior authorization form for Phentermine/Topiramate ER (Qsymia).
  •  

  • Include detailed documentation from your provider to substantiate the need for the medication.

 

Follow Up on the Prior Authorization

 

  • Contact Affinity Health Plan to verify receipt of the prior authorization request.
  •  

  • Monitor the approval process, providing additional information if requested by the insurance provider.

 

Understanding the Appeals Process

 

  • If the prior authorization is denied, read the denial letter carefully to understand the reasons.
  •  

  • Work with your healthcare provider to file an appeal, including additional supporting documentation for medical necessity.

 

Leverage Affinity Health Plan's Member Services

 

  • Utilize representative support from Affinity Health Plan to assist with any issues or questions regarding coverage specifics.
  •  

  • Request detailed information about drug formulary alternatives if needed.

 

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Does Affinity Health Plan Cover Phentermine/Topiramate ER (Qsymia)

Discover if Affinity covers Phentermine/Topiramate ER, reasons for denial, tips for coverage, costs without insurance, and FAQs in this comprehensive guide.
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Is Phentermine/Topiramate ER (Qsymia) Covered by Affinity Health Plan

 

Qsymia Coverage with Affinity Health Plan

 

  • Affinity Health Plan may cover Phentermine/Topiramate ER (Qsymia) as part of their formulary for weight management therapies.
  •  

  • Coverage often requires prior authorization. Patients generally need to meet specific criteria, including a diagnosis of obesity or weight-related conditions such as hypertension or type 2 diabetes.
  •  

  • Prescribers typically need to provide evidence that lifestyle interventions alone were insufficient for weight loss.
  •  

  • Patients may need to demonstrate adherence to a structured weight management program while on Qsymia.
  •  

  • Review specific plan details and consult with Affinity Health Plan directly to confirm coverage specifics and required documentation.

 

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Affinity Health Plan's Approved Criteria for Phentermine/Topiramate ER (Qsymia) Coverage

 

Eligibility Criteria for Phentermine/Topiramate ER (Qsymia)

 

  • Patients must be 18 years of age or older.
  •  

  • The medication is prescribed for chronic weight management in adults with an initial body mass index (BMI) of:
    • 30 kg/m² or greater (obese), or
    • 27 kg/m² or greater (overweight) in the presence of at least one weight-related comorbid condition such as hypertension, type 2 diabetes mellitus, or dyslipidemia.

     

  • A comprehensive weight management program must accompany the medication, incorporating a reduced-calorie diet and increased physical activity.
  •  

  • Patients must demonstrate previous failure with lifestyle modification alone, indicating an inability to maintain sufficient weight loss through diet and exercise.
  •  

  • Documentation of comprehensive baseline metabolic evaluation, including blood pressure, glucose levels, and lipid profile, is required to establish the necessity of the medication as part of holistic patient health management.

 

Continuation and Monitoring Criteria

 

  • A significant weight loss (at least 5% of body weight) should be observed after 12 weeks on the target dose, to continue therapy.
  •  

  • Regular follow-up visits are required, demonstrating consistent engagement with the accompanying structured weight management program, including diet and physical fitness routines.
  •  

  • Continuous monitoring for side effects, adverse reactions, and overall patient health must be documented according to healthcare provider recommendations.
  •  

  • Reevaluation of the need for Phentermine/Topiramate ER (Qsymia) is required if weight loss less than 5% is observed after 12 weeks, with potential discontinuation or adjustment of treatment strategy.

 

Why Affinity Health Plan Might Deny Phentermine/Topiramate ER (Qsymia) Coverage

 

Phentermine/Topiramate ER (Qsymia) Coverage Exclusions

 

  • Lack of Medical Necessity: Coverage may be denied if Qsymia is not deemed medically necessary for the patient's condition based on Affinity Health Plan's criteria.
  •  

  • Non-Approved Indications: Qsymia is not covered if prescribed for conditions or uses that are not FDA-approved or not recognized by Affinity Health Plan's policy.
  •  

  • Age Restrictions: Patients outside the approved age range for Qsymia may not receive coverage, as it is not indicated for use in certain age groups.
  •  

  • Failure to Meet BMI Requirements: If the patient's Body Mass Index (BMI) does not meet the specified thresholds for Qsymia coverage, it may be denied.
  •  

  • Incomplete Documentation: Insufficient or missing documentation supporting the need for Qsymia can lead to a denial of coverage.
  •  

  • Prior Authorization: Failure to obtain prior authorization from Affinity Health Plan may result in non-coverage.
  •  

  • Exclusion of Lifestyle Drugs: Qsymia may be categorized under lifestyle medications, which are often excluded from coverage by some health plans.
  •  

  • Financial Limit Exceedance: Cases where the cost of the prescription surpasses the financial limits set by the insurance policy may see denial of coverage.
  •  

  • Alternative Therapies Requirement: If less expensive or different therapeutic approaches are available and have not been tried, coverage may be denied.
  •  

  • Quantity Limits: Exceeding the allowed quantity dispensed per prescription period could result in a denial of coverage.

 

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How Much Does Phentermine/Topiramate ER (Qsymia) Cost without Insurance?

 

Cost of Phentermine/Topiramate ER (Qsymia) Without Insurance

 

  • The average retail price for Phentermine/Topiramate ER (Qsymia), a medication typically prescribed for weight loss, ranges from $120 to $240 for a 30-day supply, depending on the pharmacy and location.
  •  

  • Prices may vary slightly due to specific factors such as dosage strength, with differing costs for varying dosages like 3.75 mg/23 mg, 7.5 mg/46 mg, 11.25 mg/69 mg, and 15 mg/92 mg.
  •  

  • Discount programs or pharmacy coupons might offer lower prices, potentially reducing the cost to as low as $100 for a monthly supply. It is advisable for patients to explore these options for financial relief.
  •  

  • Some pharmacies provide price matching, which can be helpful in securing the best available price without insurance.
  •  

  • Patients should check for any available manufacturer's savings programs or patient assistance plans that might further aid in reducing 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 Phentermine/Topiramate ER (Qsymia) Coverage with Affinity Health Plan

 

Understanding Your Coverage with Affinity Health Plan

 

  • Review your plan details for prescription drug coverage related to weight management medications.
  •  

  • Contact Affinity Health Plan customer service to confirm specific coverage for Phentermine/Topiramate ER (Qsymia).

 

Consult with Your Healthcare Provider

 

  • Discuss the potential benefits and appropriateness of Phentermine/Topiramate ER (Qsymia) for your health needs.
  •  

  • Have your healthcare provider document the medical necessity for the medication. This documentation will be crucial for insurance approval.

 

Utilize the Affinity Health Plan Provider Network

 

  • Select a healthcare provider within the Affinity Health Plan network to reduce out-of-pocket costs.
  •  

  • Your in-network provider can directly handle authorizations and communications with the insurance company.

 

Complete a Prior Authorization Request

 

  • Work with your healthcare provider to complete and submit a prior authorization form for Phentermine/Topiramate ER (Qsymia).
  •  

  • Include detailed documentation from your provider to substantiate the need for the medication.

 

Follow Up on the Prior Authorization

 

  • Contact Affinity Health Plan to verify receipt of the prior authorization request.
  •  

  • Monitor the approval process, providing additional information if requested by the insurance provider.

 

Understanding the Appeals Process

 

  • If the prior authorization is denied, read the denial letter carefully to understand the reasons.
  •  

  • Work with your healthcare provider to file an appeal, including additional supporting documentation for medical necessity.

 

Leverage Affinity Health Plan's Member Services

 

  • Utilize representative support from Affinity Health Plan to assist with any issues or questions regarding coverage specifics.
  •  

  • Request detailed information about drug formulary alternatives if needed.

 

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.

Phentermine/Topiramate ER (Qsymia) FAQ

What are the common side effects of Phentermine/Topiramate ER (Qsymia)?

 

Common Side Effects of Qsymia

 

  • **Paraesthesia:** Often described as a tingling sensation, typically in the hands and feet.
  •  

  • **Dizziness and lightheadedness:** These sensations may occur, especially when standing up quickly.
  •  

  • **Dry mouth:** Increased thirst or the feeling of not having enough saliva can be common with Qsymia use.
  •  

  • **Insomnia:** Difficulty falling asleep or staying asleep may be experienced.
  •  

  • **Constipation:** A common digestive side effect, characterized by infrequent bowel movements.
  •  

  • **Taste alteration:** Some users report a change in taste perception or a metallic taste.

How effective is Qsymia for weight loss?

 

Effectiveness of Qsymia

 

  • Qsymia combines phentermine and topiramate ER, proven effective for weight loss by enhancing satiety and reducing appetite.
  •  

  • Clinical trials report an average weight loss of about 5%–10% of initial body weight over a year, higher than diet and exercise alone.
  •  

  • Study results can vary based on individual factors such as diet adherence and lifestyle changes.
  •  

 

Considerations

 

  • Best results occur alongside a reduced-calorie diet and increased physical activity.
  •  

  • Assess for potential side effects, including increased heart rate, mood changes, and birth defects if used during pregnancy.
  •  

  • Long-term efficacy beyond one year is less established, requiring ongoing lifestyle modifications for sustained weight management.

 

Can Qsymia be taken long-term for weight management?

 

Long-term Use of Qsymia

 

  • Qsymia is an obesity medication combining phentermine and topiramate. It's approved for long-term use along with a reduced-calorie diet and increased physical activity.
  •  

  • Potential benefits include sustainable weight loss, improved metabolic health, and reduced risk of obesity-related conditions.

 

Monitoring and Safety

 

  • Regular follow-ups with a healthcare provider are essential to monitor side effects and effectiveness.
  •  

  • Common side effects include numbness, dizziness, taste changes, and insomnia. More severe risks include mood alterations and birth defects.

 

Continuing Treatment

 

  • Periodic assessment is crucial to decide if continued treatment is appropriate based on weight loss progress and side effect profile.
  •  

  • Should significant weight loss not occur within 12 weeks, alternative therapies might be considered.

 

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Your initial medication and dosage are carefully determined by doctors, taking into account your unique health profile. This ensures a personalized and safe treatment plan tailored to your specific needs.

Titration

We gradually adjust your dosage to reach the optimal therapeutic level, ensuring maximum effectiveness while minimizing potential side effects.

Additional Treatments

Our providers may also recommend medications such as metformin or supplements such as vitamin B12. We recognize the importance of managing side effects, so your care plan may include medication to alleviate them.

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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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