Does Blue Cross Blue Shield of Alabama Cover Phentermine/Topiramate ER (Qsymia)

Explore coverage details for Phentermine/Topiramate ER (Qsymia) by Blue Cross Blue Shield of Alabama, including potential cost and tips for securing coverage.
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Coverage for Phentermine/Topiramate ER (Qsymia)

 

  • Blue Cross Blue Shield of Alabama may cover Phentermine/Topiramate ER (Qsymia) for individuals diagnosed with obesity or overweight conditions associated with at least one weight-related comorbidity.
  •  

  • Candidates usually need to provide evidence of previous unsuccessful weight loss efforts and require a Body Mass Index (BMI) of 30 kg/m² or higher, or 27 kg/m² with additional risk factors.
  •  

    Prior Authorization and Medical Criteria

     

  • Patients must obtain prior authorization, which involves a healthcare provider submitting relevant medical documentation to demonstrate medical necessity.
  •  

  • Coverage typically requires that the prescription is part of a comprehensive weight management plan, encompassing lifestyle changes such as diet and exercise.
  •  

    Exclusions and Conditions

     

  • Coverage may exclude individuals with specific health conditions or certain concurrent treatments, as contraindicated by the drug's prescribing information.
  •  

  • Follow-up appointments to monitor effectiveness and any side effects might be necessary to continue coverage.

 

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Curex is poised to revolutionize the way allergies are treated in America, expanding access to clinical care and treatments that can meaningfully improve patients quality of life.

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At Curex, our mission is to help people improve their health and quality of life by understanding their allergies and treating them at their source.We provide more than individualized prescription treatments; we provide individualized care.

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Immunotherapy made simple.  We enable patients to receive personalized allergy care on their own time. No more waiting rooms.

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 Blue Cross Blue Shield of Alabama

 

Verify Coverage Eligibility

 

  • Contact Blue Cross Blue Shield of Alabama customer service to determine if Phentermine/Topiramate ER (Qsymia) is covered under your specific insurance plan.
  •  

  • Check your policy details in your member portal to review prescription drug coverage options and any exclusions.

 

Obtain Necessary Documentation

 

  • Schedule an appointment with your healthcare provider to discuss your eligibility for Phentermine/Topiramate ER (Qsymia) based on medical necessity.
  •  

  • Ensure your healthcare provider is prepared to provide a letter of medical necessity if required by your insurance for coverage authorization.

 

Submit a Prior Authorization Request

 

  • Ask your healthcare provider to submit a prior authorization request to Blue Cross Blue Shield of Alabama, including all necessary documentation for Phentermine/Topiramate ER (Qsymia).
  •  

  • Ensure that the request includes comprehensive information to justify the need for this specific treatment based on your health condition.

 

Follow-Up with Your Provider

 

  • Regularly check with your healthcare provider’s office to confirm that the authorization request has been sent and is being processed.
  •  

  • Inquire about any additional information or documentation that your provider may need to submit.

 

Monitor the Authorization Process

 

  • Log into your Blue Cross Blue Shield of Alabama member account to track the status of your prior authorization request.
  •  

  • Contact Blue Cross Blue Shield of Alabama for updates if the process is taking longer than expected.

 

Appeal if Necessary

 

  • If your coverage request is denied, consult with your healthcare provider to gather any additional information or clarification needed to support your case.
  •  

  • Follow the appeal procedures provided by Blue Cross Blue Shield of Alabama, ensuring that you meet any deadlines for submitting an appeal.

 

Utilize Blue Cross Blue Shield of Alabama Resources

 

  • Access any available resources or support services provided by Blue Cross Blue Shield of Alabama for medication management or case handling.
  •  

  • Request assistance from a case manager or patient advocate if additional help is needed during the coverage process.

 

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Does Blue Cross Blue Shield of Alabama Cover Phentermine/Topiramate ER (Qsymia)

Explore coverage details for Phentermine/Topiramate ER (Qsymia) by Blue Cross Blue Shield of Alabama, including potential cost and tips for securing coverage.
Curex allergy drops unboxing

Is Phentermine/Topiramate ER (Qsymia) Covered by Blue Cross Blue Shield of Alabama

 

Coverage for Phentermine/Topiramate ER (Qsymia)

 

  • Blue Cross Blue Shield of Alabama may cover Phentermine/Topiramate ER (Qsymia) for individuals diagnosed with obesity or overweight conditions associated with at least one weight-related comorbidity.
  •  

  • Candidates usually need to provide evidence of previous unsuccessful weight loss efforts and require a Body Mass Index (BMI) of 30 kg/m² or higher, or 27 kg/m² with additional risk factors.
  •  

    Prior Authorization and Medical Criteria

     

  • Patients must obtain prior authorization, which involves a healthcare provider submitting relevant medical documentation to demonstrate medical necessity.
  •  

  • Coverage typically requires that the prescription is part of a comprehensive weight management plan, encompassing lifestyle changes such as diet and exercise.
  •  

    Exclusions and Conditions

     

  • Coverage may exclude individuals with specific health conditions or certain concurrent treatments, as contraindicated by the drug's prescribing information.
  •  

  • Follow-up appointments to monitor effectiveness and any side effects might be necessary to continue coverage.

 

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Blue Cross Blue Shield of Alabama's Approved Criteria for Phentermine/Topiramate ER (Qsymia) Coverage

 

Eligibility Criteria for Coverage

 

  • The patient must be 18 years of age or older.
  •  

  • The patient must have a Body Mass Index (BMI) of 30 kg/m² or greater.
  •  

  • Alternatively, the patient should have a BMI of 27 kg/m² or greater with at least one weight-related comorbid condition, such as hypertension, type 2 diabetes, or dyslipidemia.

 

Previous Weight-Loss Attempts

 

  • The patient must have tried to lose weight through diet and exercise without success.
  •  

  • Documentation of prior weight loss attempts, including lifestyle changes and use of other weight loss medications, should be provided.

 

Prescriber Requirements

 

  • The prescription must be written by or in consultation with an endocrinologist, bariatric specialist, or a healthcare provider specializing in weight management.

 

Continued Therapy Criteria

 

  • Continued coverage of Phentermine/Topiramate ER (Qsymia) is contingent on achieving a health benefit such as a significant reduction in body weight from baseline.
  •  

  • The patient must demonstrate at least a 5% reduction in body weight by 12 weeks of treatment initiation to continue therapy.

 

Documentation and Monitoring

 

  • Healthcare providers must submit documentation supporting the initial criteria and ongoing response to therapy at regular intervals.
  •  

  • Regular follow-up appointments should be scheduled to monitor the patient's progress, side effects, and adherence to treatment.

 

Additional Requirements

 

  • The medication should not be covered under any other policy terms that exclude weight loss treatments or have specific limitations on weight management medications.
  • All relevant clinical and medical notes should be provided for initial and ongoing approval.

 

Why Blue Cross Blue Shield of Alabama Might Deny Phentermine/Topiramate ER (Qsymia) Coverage

 

Criteria for Denial of Qsymia Coverage by Blue Cross Blue Shield of Alabama

 

  • Patient does not meet the minimum BMI requirements set by Blue Cross Blue Shield of Alabama for weight management medications.
  •  

  • The prescribing physician is not a member of the Blue Cross Blue Shield of Alabama provider network.
  •  

  • Qsymia is prescribed for off-label use or purposes not approved by the Food and Drug Administration (FDA).
  •  

  • The patient has not demonstrated a history of unsuccessful weight loss attempts with diet and lifestyle modifications, which may be a prerequisite for approval.
  •  

  • Prescriptions exceeding the recommended dosage or quantity limits set by Blue Cross Blue Shield of Alabama without proper authorization or documentation.
  •  

  • Inadequate documentation or failure to provide required medical records and history justifying the need for Qsymia.
  •  

  • Lack of prior authorization from Blue Cross Blue Shield of Alabama if such a process is mandated by the policy.
  •  

  • Patient's plan does not include coverage for weight management medications, such as Qsymia.

 

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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 Blue Cross Blue Shield of Alabama

 

Verify Coverage Eligibility

 

  • Contact Blue Cross Blue Shield of Alabama customer service to determine if Phentermine/Topiramate ER (Qsymia) is covered under your specific insurance plan.
  •  

  • Check your policy details in your member portal to review prescription drug coverage options and any exclusions.

 

Obtain Necessary Documentation

 

  • Schedule an appointment with your healthcare provider to discuss your eligibility for Phentermine/Topiramate ER (Qsymia) based on medical necessity.
  •  

  • Ensure your healthcare provider is prepared to provide a letter of medical necessity if required by your insurance for coverage authorization.

 

Submit a Prior Authorization Request

 

  • Ask your healthcare provider to submit a prior authorization request to Blue Cross Blue Shield of Alabama, including all necessary documentation for Phentermine/Topiramate ER (Qsymia).
  •  

  • Ensure that the request includes comprehensive information to justify the need for this specific treatment based on your health condition.

 

Follow-Up with Your Provider

 

  • Regularly check with your healthcare provider’s office to confirm that the authorization request has been sent and is being processed.
  •  

  • Inquire about any additional information or documentation that your provider may need to submit.

 

Monitor the Authorization Process

 

  • Log into your Blue Cross Blue Shield of Alabama member account to track the status of your prior authorization request.
  •  

  • Contact Blue Cross Blue Shield of Alabama for updates if the process is taking longer than expected.

 

Appeal if Necessary

 

  • If your coverage request is denied, consult with your healthcare provider to gather any additional information or clarification needed to support your case.
  •  

  • Follow the appeal procedures provided by Blue Cross Blue Shield of Alabama, ensuring that you meet any deadlines for submitting an appeal.

 

Utilize Blue Cross Blue Shield of Alabama Resources

 

  • Access any available resources or support services provided by Blue Cross Blue Shield of Alabama for medication management or case handling.
  •  

  • Request assistance from a case manager or patient advocate if additional help is needed during the coverage process.

 

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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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Titration

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

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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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