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Does Anthem Cover Phentermine/Topiramate ER (Qsymia)

Discover if Anthem covers Qsymia, reasons for possible denial, tips to secure coverage, out-of-pocket costs, and answers to common questions.
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Coverage for Phentermine/Topiramate ER (Qsymia)

 

  • Anthem generally covers Qsymia for weight loss in cases where it's medically necessary. Typically, this includes patients with a BMI ≥ 30, or ≥ 27 with weight-related conditions such as hypertension, type 2 diabetes, or dyslipidemia.

    •  

  • Coverage criteria may require exhausting other weight-loss options, like lifestyle changes, before approving medications.

 

Getting Qsymia Covered

 

  • Patients must present documentation from healthcare providers outlining the medical necessity of the medication.

    •  

  • Prior authorization might be needed, requiring a review of a patient's medical history and other treatment attempts.

    •  

  • It's essential for patients to consult Anthem's specific policy documents or speak to a representative for precise coverage details as guidelines are subject to change.

 

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Clinical Support

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 Anthem

 

Verify Insurance Policy Details

 

  • Contact Anthem customer service to verify your specific policy details. Ask if Phentermine/Topiramate ER (Qsymia) is included in your pharmacy benefits.
  • Check if there are any pre-authorization requirements or limitations specific to weight-loss medications or this particular drug.

 

Consult with Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss the possibility of using Phentermine/Topiramate ER (Qsymia) as part of your weight management plan.
  • Your provider can help assess if this medication is appropriate and provide any necessary medical documentation needed for insurance purposes.

 

Request a Prior Authorization

 

  • If required, ask your healthcare provider to initiate a prior authorization request with Anthem. This process usually involves your doctor providing detailed medical justification for prescribing Qsymia.
  • Ensure that the documentation addresses any specific criteria or guidelines outlined by Anthem for coverage of this medication.

 

Submit Necessary Documentation

 

  • Gather all required documents, including your healthcare provider's prescription and prior authorization forms.
  • Submit these documents to Anthem as instructed, either through an online portal, by fax, or through mail, depending on their preferred method.

 

Follow Up with Anthem

 

  • Monitor the status of your prior authorization request by contacting Anthem’s customer service, or checking any online tracking systems they might offer.
  • Be proactive about following up if you don't receive a timely response or if there are any omissions or errors in the documentation.

 

Appeal if Necessary

 

  • If your request for coverage is denied, review the denial letter carefully for reasons and learn about the procedure for submitting an appeal.
  • Work with your healthcare provider to address any issues raised and submit additional medical documentation or clarification to support your appeal.

 

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Does Anthem Cover Phentermine/Topiramate ER (Qsymia)

Discover if Anthem covers Qsymia, reasons for possible denial, tips to secure coverage, out-of-pocket costs, and answers to common questions.
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Is Phentermine/Topiramate ER (Qsymia) Covered by Anthem

 

Coverage for Phentermine/Topiramate ER (Qsymia)

 

  • Anthem generally covers Qsymia for weight loss in cases where it's medically necessary. Typically, this includes patients with a BMI ≥ 30, or ≥ 27 with weight-related conditions such as hypertension, type 2 diabetes, or dyslipidemia.

    •  

  • Coverage criteria may require exhausting other weight-loss options, like lifestyle changes, before approving medications.

 

Getting Qsymia Covered

 

  • Patients must present documentation from healthcare providers outlining the medical necessity of the medication.

    •  

  • Prior authorization might be needed, requiring a review of a patient's medical history and other treatment attempts.

    •  

  • It's essential for patients to consult Anthem's specific policy documents or speak to a representative for precise coverage details as guidelines are subject to change.

 

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

 

Criteria for Coverage of Phentermine/Topiramate ER (Qsymia) by Anthem

 

  • The patient must have a documented diagnosis of obesity, defined as a Body Mass Index (BMI) of 30 kg/m2 or greater.

    •  

  • Alternatively, coverage may be provided for patients with a BMI of 27 kg/m2 or greater who have a documented medical condition related to weight, such as type 2 diabetes, dyslipidemia, or hypertension.

    •  

  • The patient must have attempted prior weight loss efforts through lifestyle modifications, including a reduced-calorie diet and increased physical activity, without achieving significant weight reduction.

    •  

  • A healthcare provider must present a detailed treatment plan that incorporates Qsymia as part of a comprehensive weight management plan.

    •  

  • There should be no contraindications present, such as pregnancy or known hypersensitivity to the drug or its components.

    •  

  • The healthcare provider must document ongoing monitoring and assessment of the patient’s progress, with a specific plan for dosage adjustment or discontinuation based on effectiveness and tolerance.

    •  

 

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

 

Exclusions for Phentermine/Topiramate ER (Qsymia) Coverage by Anthem

 

  • Anthem does not cover Qsymia for individuals who do not meet the necessary Body Mass Index (BMI) requirements. This generally includes those with a BMI below 30, or below 27 with accompanying weight-related conditions such as hypertension, type 2 diabetes, or dyslipidemia.

    •  

  • Coverage for Qsymia is denied if the individual has not participated in a lifestyle modification program such as diet, exercise, or behavior therapy. Documentation of efforts in such programs is often required.

    •  

  • Anthem may deny coverage for Qsymia if there is insufficient detailed patient medical history provided, making it difficult to justify medical necessity.

    •  

  • Individuals who have not been assessed for contraindications such as unstable cardiac or cerebrovascular disease, in pregnancy or planning to become pregnant, or having a history of hypersensitivity to sympathomimetic amines, may not receive coverage.

    •  

  • Anthem excludes coverage if there is evidence of misuse or abuse of the medication, or if it is being used as an initial weight loss effort without prior attempts with alternative therapies.

    •  

  • Patients with a history of drug or alcohol abuse may face denial of coverage due to concerns over potential misuse of the medication.

    •  

  • Requests for Qsymia coverage for individuals under 18 years of age are not typically approved, as the medication is generally not recommended for this population.

    •  

 

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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.

 

Clinical Support

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 Anthem

 

Verify Insurance Policy Details

 

  • Contact Anthem customer service to verify your specific policy details. Ask if Phentermine/Topiramate ER (Qsymia) is included in your pharmacy benefits.
  • Check if there are any pre-authorization requirements or limitations specific to weight-loss medications or this particular drug.

 

Consult with Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss the possibility of using Phentermine/Topiramate ER (Qsymia) as part of your weight management plan.
  • Your provider can help assess if this medication is appropriate and provide any necessary medical documentation needed for insurance purposes.

 

Request a Prior Authorization

 

  • If required, ask your healthcare provider to initiate a prior authorization request with Anthem. This process usually involves your doctor providing detailed medical justification for prescribing Qsymia.
  • Ensure that the documentation addresses any specific criteria or guidelines outlined by Anthem for coverage of this medication.

 

Submit Necessary Documentation

 

  • Gather all required documents, including your healthcare provider's prescription and prior authorization forms.
  • Submit these documents to Anthem as instructed, either through an online portal, by fax, or through mail, depending on their preferred method.

 

Follow Up with Anthem

 

  • Monitor the status of your prior authorization request by contacting Anthem’s customer service, or checking any online tracking systems they might offer.
  • Be proactive about following up if you don't receive a timely response or if there are any omissions or errors in the documentation.

 

Appeal if Necessary

 

  • If your request for coverage is denied, review the denial letter carefully for reasons and learn about the procedure for submitting an appeal.
  • Work with your healthcare provider to address any issues raised and submit additional medical documentation or clarification to support your appeal.

 

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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.

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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.

 

Have questions left?

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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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Curex provides allergy care plans for allergies, asthma, eczema and pet allergies.

Curex providers may prescribe sublingual allergy drops that contain the same ingredients as allergy shots but are more convenient & affordable.
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