Does Amerigroup Cover Phentermine/Topiramate ER (Qsymia)

Explore Amerigroup's coverage for Phentermine/Topiramate ER (Qsymia), reasons for denial, and tips for obtaining coverage. Cost insights and FAQs included.
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Coverage for Phentermine/Topiramate ER (Qsymia) with Amerigroup

 

  • Amerigroup may cover Phentermine/Topiramate ER (Qsymia) for individuals with a confirmed diagnosis of obesity or those meeting specific Body Mass Index (BMI) criteria.
  •  

  • Patients typically need to demonstrate a history of unsuccessful weight loss attempts through diet and exercise alone.
  •  

  • Health conditions such as type 2 diabetes or hypertension may increase the likelihood of coverage approval.
  •  

  • A prior authorization process is commonly required, where a healthcare provider must verify the medical necessity and submit relevant patient history.
  •  

  • Coverage rules and criteria can vary by state and specific plan, so consulting Amerigroup's member services can provide tailored information for individual circumstances.

 

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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 Amerigroup

 

Verify Eligibility and Benefits

 

  • Contact Amerigroup's customer service by calling the number on the back of your insurance card to confirm coverage for Phentermine/Topiramate ER (Qsymia). Alternatively, check your benefits online through Amerigroup's member portal.
  •  

  • Ask for specific details about any requirements for coverage, such as prior authorization, step therapy, or any other restrictions linked to this medication.

 

Consult with Your Healthcare Provider

 

  • Discuss the necessity and appropriateness of Phentermine/Topiramate ER (Qsymia) with your healthcare provider. They will evaluate whether this medication suits your medical needs.
  •  

  • If your provider agrees with the treatment plan, ask them to prepare any necessary documentation or justification Amerigroup might require.

 

Obtain Prior Authorization

 

  • Your healthcare provider must submit a prior authorization request to Amerigroup. This typically involves completing a form detailing your medical history and the necessity of Phentermine/Topiramate ER (Qsymia) for your treatment.
  •  

  • Ensure your provider includes all relevant documentation to support the request, including any previous medications tried, relevant test results, and rationales for selecting Qsymia.

 

Follow Up with Amerigroup

 

  • Keep in touch periodically with Amerigroup to check the status of your prior authorization request. This may require contacting their pharmacy department or member services.
  •  

  • Be prepared to provide any additional information or clarification that Amerigroup may request to process your authorization.

 

Explore Appeals If Necessary

 

  • If your prior authorization request is denied, request the specific reasons for the denial from Amerigroup.
  •  

  • Work with your healthcare provider to address the issues and proceed with an appeal. This can involve submitting additional medical evidence or providing further specialist opinions.
  •  

  • Ensure that all appeal submissions are tracked and recorded, and follow up regularly for updates.

 

Consider Financial Assistance Programs

 

  • Check if there are any manufacturer programs or financial assistance options for Qsymia if there are concerns about copays or payment, even if it’s partially covered.
  •  

  • Consult with your healthcare provider or Amerigroup about any such options, and apply as necessary.

 

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Does Amerigroup Cover Phentermine/Topiramate ER (Qsymia)

Explore Amerigroup's coverage for Phentermine/Topiramate ER (Qsymia), reasons for denial, and tips for obtaining coverage. Cost insights and FAQs included.
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Is Phentermine/Topiramate ER (Qsymia) Covered by Amerigroup

 

Coverage for Phentermine/Topiramate ER (Qsymia) with Amerigroup

 

  • Amerigroup may cover Phentermine/Topiramate ER (Qsymia) for individuals with a confirmed diagnosis of obesity or those meeting specific Body Mass Index (BMI) criteria.
  •  

  • Patients typically need to demonstrate a history of unsuccessful weight loss attempts through diet and exercise alone.
  •  

  • Health conditions such as type 2 diabetes or hypertension may increase the likelihood of coverage approval.
  •  

  • A prior authorization process is commonly required, where a healthcare provider must verify the medical necessity and submit relevant patient history.
  •  

  • Coverage rules and criteria can vary by state and specific plan, so consulting Amerigroup's member services can provide tailored information for individual circumstances.

 

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Amerigroup's Approved Criteria for Phentermine/Topiramate ER (Qsymia) Coverage

 

Eligibility Criteria for Amerigroup Phentermine/Topiramate ER (Qsymia) Coverage

 

  • Patients must have a Body Mass Index (BMI) of 30 kg/m² or greater (obesity) or a BMI of 27 kg/m² or greater (overweight) in the presence of at least one weight-related comorbid condition such as type 2 diabetes mellitus, hypertension, or dyslipidemia.
  •  

  • There should be prior unsuccessful attempts to lose weight through a structured diet and exercise program documented in the patient's medical records.
  •  

  • The patient should not have used Phentermine/Topiramate ER (Qsymia) within the past six months unless a documented reason exists for resuming therapy.
  •  

  • A prescription must be issued by a licensed healthcare provider skilled in weight management.
  •  

  • The patient must not have any contraindications to treatment as outlined in the prescribing information, such as pregnancy or glaucoma.

 

Additional Condition for Coverage Continuation

 

  • Continuation of coverage requires documentation of positive response to therapy, defined by at least 5% weight loss from baseline at the end of 12 weeks of treatment.
  •  

  • The progress toward weight loss goals should be assessed regularly, with detailed records maintained as a part of the patient's health care provider's regular monitoring and follow-up appointments.

 

Clinical Documentation Required for Coverage

 

  • Medical records detailing the patient's BMI and any comorbid conditions.
  •  

  • Records showing previous weight loss efforts and outcomes, highlighting methods used and duration.
  •  

  • Communication notes from healthcare provider explaining past medication use and anticipated benefits from resuming Phentermine/Topiramate ER (Qsymia) if applicable.
  •  

  • Any provider notes or patient assessments regarding patient's commitment and adherence to a comprehensive weight management program.

 

Why Amerigroup Might Deny Phentermine/Topiramate ER (Qsymia) Coverage

 

Reasons Amerigroup Might Deny Coverage for Phentermine/Topiramate ER (Qsymia)

 

  • Phentermine/Topiramate ER (Qsymia) is not approved for patients with a history of cardiovascular disease, such as coronary artery disease or heart attack, since these conditions may increase risks associated with the medication.
  •  

  • The medication is not covered for individuals with an uncontrolled hyperthyroidism diagnosis. The condition contraindicates use due to potential exacerbation.
  •  

  • Amerigroup does not cover this medication if the patient is pregnant or planning to become pregnant due to risks of teratogenicity and potential adverse effects on fetal development.
  •  

  • Coverage may be denied if the patient has a history of glaucoma, as Qsymia can potentially increase intraocular pressure, worsening this condition.
  •  

  • The medication is not covered for patients with a history of drug abuse, given the potential for misuse or dependency associated with one of its components, phentermine.
  •  

  • Amerigroup may also deny coverage if the patient is currently using a monoamine oxidase inhibitor (MAOI) or has discontinued use of an MAOI in the last 14 days, due to potential drug interactions.
  •  

  • Patients without a documented body mass index (BMI) of 30 kg/m² or higher, or those with a BMI of 27 kg/m² or higher with weight-related comorbid conditions, may not be eligible for 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 Amerigroup

 

Verify Eligibility and Benefits

 

  • Contact Amerigroup's customer service by calling the number on the back of your insurance card to confirm coverage for Phentermine/Topiramate ER (Qsymia). Alternatively, check your benefits online through Amerigroup's member portal.
  •  

  • Ask for specific details about any requirements for coverage, such as prior authorization, step therapy, or any other restrictions linked to this medication.

 

Consult with Your Healthcare Provider

 

  • Discuss the necessity and appropriateness of Phentermine/Topiramate ER (Qsymia) with your healthcare provider. They will evaluate whether this medication suits your medical needs.
  •  

  • If your provider agrees with the treatment plan, ask them to prepare any necessary documentation or justification Amerigroup might require.

 

Obtain Prior Authorization

 

  • Your healthcare provider must submit a prior authorization request to Amerigroup. This typically involves completing a form detailing your medical history and the necessity of Phentermine/Topiramate ER (Qsymia) for your treatment.
  •  

  • Ensure your provider includes all relevant documentation to support the request, including any previous medications tried, relevant test results, and rationales for selecting Qsymia.

 

Follow Up with Amerigroup

 

  • Keep in touch periodically with Amerigroup to check the status of your prior authorization request. This may require contacting their pharmacy department or member services.
  •  

  • Be prepared to provide any additional information or clarification that Amerigroup may request to process your authorization.

 

Explore Appeals If Necessary

 

  • If your prior authorization request is denied, request the specific reasons for the denial from Amerigroup.
  •  

  • Work with your healthcare provider to address the issues and proceed with an appeal. This can involve submitting additional medical evidence or providing further specialist opinions.
  •  

  • Ensure that all appeal submissions are tracked and recorded, and follow up regularly for updates.

 

Consider Financial Assistance Programs

 

  • Check if there are any manufacturer programs or financial assistance options for Qsymia if there are concerns about copays or payment, even if it’s partially covered.
  •  

  • Consult with your healthcare provider or Amerigroup about any such options, and apply as necessary.

 

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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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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.

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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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