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

Discover if Blue Cross Blue Shield of Massachusetts covers Phentermine/Topiramate ER (Qsymia), why they might deny it, costs without insurance, and frequently asked questions.
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Coverage for Phentermine/Topiramate ER (Qsymia)

 

  • Blue Cross Blue Shield of Massachusetts may provide coverage for Phentermine/Topiramate ER (Qsymia) under certain medical conditions. Eligibility often includes patients diagnosed with obesity-related conditions, such as a body mass index (BMI) ≥30 kg/m², or a BMI ≥27 kg/m² with associated risk factors like hypertension, type 2 diabetes, or hyperlipidemia.
  •  

  • Prior authorization may be required, demonstrating that Qsymia is medically necessary for the patient. This usually involves documentation from healthcare providers detailing prior weight-loss attempts and the patient's health condition.
  •  

  • Adherence to the prescribed treatment plan must be shown, including regular follow-up evaluations to assess the drug's effectiveness and side effects.
  •  

  • Coverage details can vary depending on specific plans and additional riders; thus, it's recommended to verify with Blue Cross Blue Shield of Massachusetts directly or review plan-specific documents.

 

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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.

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 Massachusetts

 

Understand Your Insurance Plan

 

  • Review your Blue Cross Blue Shield of Massachusetts (BCBSMA) health insurance plan documentation to understand your prescription drug coverage.
  •  

  • Check if Phentermine/Topiramate ER (Qsymia) is listed in your plan’s formulary, which is the list of drugs covered by your insurance.

 

Consult with Your Healthcare Provider

 

  • Discuss your need for Phentermine/Topiramate ER (Qsymia) with your healthcare provider. Ensure they understand your medical history and weight management needs.
  •  

  • If your doctor finds it appropriate, obtain a prescription for Qsymia. Ensure the doctor provides any required clinical documentation to support the necessity of this medication.

 

Verify Coverage Prerequisites

 

  • Determine if BCBSMA requires a prior authorization for Qsymia. This step verifies the medical necessity of the prescription before coverage is granted.
  •  

  • Inquire about any specific criteria you must meet, such as Body Mass Index (BMI) thresholds or documentation of previous weight management attempts.

 

Initiate Prior Authorization Process

 

  • Contact your doctor’s office to initiate the prior authorization process. They will work with BCBSMA to submit the necessary paperwork.
  •  

  • Provide your healthcare provider with any additional information or documentation required by BCBSMA during the authorization process.

 

Follow Up on the Authorization

 

  • Regularly check with your healthcare provider and BCBSMA on the status of your prior authorization request.
  •  

  • Be prepared to provide any additional information or clarification if BCBSMA requests further details.

 

Appeal Denied Authorizations

 

  • If your prior authorization is denied, review the reasons for denial with your healthcare provider to determine if you can address those issues.
  •  

  • Consider filing an appeal with BCBSMA, providing additional supportive medical information or a letter from your doctor explaining the necessity for Qsymia.

 

Monitor Your Medication Utilization

 

  • Once approved, follow your healthcare provider’s directions for using Qsymia and adhere to BCBSMA’s utilization guidelines.
  •  

  • Keep records of your prescription refills and any correspondence with BCBSMA regarding your coverage.

 

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

Discover if Blue Cross Blue Shield of Massachusetts covers Phentermine/Topiramate ER (Qsymia), why they might deny it, costs without insurance, and frequently asked questions.
Curex allergy drops unboxing

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

 

Coverage for Phentermine/Topiramate ER (Qsymia)

 

  • Blue Cross Blue Shield of Massachusetts may provide coverage for Phentermine/Topiramate ER (Qsymia) under certain medical conditions. Eligibility often includes patients diagnosed with obesity-related conditions, such as a body mass index (BMI) ≥30 kg/m², or a BMI ≥27 kg/m² with associated risk factors like hypertension, type 2 diabetes, or hyperlipidemia.
  •  

  • Prior authorization may be required, demonstrating that Qsymia is medically necessary for the patient. This usually involves documentation from healthcare providers detailing prior weight-loss attempts and the patient's health condition.
  •  

  • Adherence to the prescribed treatment plan must be shown, including regular follow-up evaluations to assess the drug's effectiveness and side effects.
  •  

  • Coverage details can vary depending on specific plans and additional riders; thus, it's recommended to verify with Blue Cross Blue Shield of Massachusetts directly or review plan-specific documents.

 

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

 

Eligibility Criteria for Phentermine/Topiramate ER (Qsymia) Coverage

 

  • Patient must have a diagnosis of obesity, defined as a Body Mass Index (BMI) greater than or equal to 30 kg/m², or a BMI greater than or equal to 27 kg/m² with one or more weight-related comorbid conditions (such as hypertension, type 2 diabetes, or dyslipidemia).
  •  

  • Patient must have documented evidence of a failed attempt to achieve weight loss through diet and exercise alone, demonstrated by at least a six-month trial.
  •  

  • Prescribing physician must be a specialist in obesity management or must provide evidence of expertise in managing obesity, which could include experience in treating similar patients or completion of specialized training or certification in weight management.
  •  

  • Coverage is contingent upon agreement to discontinue the medication if effective weight loss (defined as a significant reduction in weight or BMI) is not achieved at 12 weeks at the target dose.
  •  

  • Patient should not be using any other weight loss medications concurrently, unless specifically approved by Blue Cross Blue Shield of Massachusetts for combination therapy.

 

Documentation and Review Requirements

 

  • Initial request for coverage must include documentation of the patient's BMI, relevant comorbid conditions, and past weight loss attempts, along with a comprehensive treatment plan that includes diet and exercise.
  •  

  • Regular follow-up consultations must be documented to monitor the effectiveness and safety of the medication, with updates submitted to Blue Cross Blue Shield of Massachusetts as required.
  •  

  • Any adverse reactions or issues must be promptly reported and evaluated for continued coverage consideration.

 

Renewal Criteria

 

  • Renewal requests must demonstrate continued effectiveness of Phentermine/Topiramate ER, with evidence of sustained weight loss and maintenance of any comorbid condition improvements.
  •  

  • Updated documentation from recent health assessments must be provided, including patient adherence to the prescribed medication and lifestyle recommendations.
  •  

  • Patient must demonstrate no new contraindications or serious side effects that would necessitate discontinuation of the medication.

 

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

 

Reasons for Denial of Phentermine/Topiramate ER (Qsymia) Coverage

 

  • Not meeting the BMI criteria: Blue Cross Blue Shield of Massachusetts may deny coverage if the individual's body mass index (BMI) is below the required threshold for obesity treatment.
  •  

  • Lacking specific comorbid conditions: Coverage might be denied if the patient does not have at least one comorbid condition such as type 2 diabetes, hypertension, or dyslipidemia alongside obesity, as specified in their policy.
  •  

  • Previous medical history: If there is a history of substance abuse or specific contraindicated cardiovascular problems, coverage for Phentermine/Topiramate ER (Qsymia) could be denied.
  •  

  • Absence of a medically supervised weight-loss program: Blue Cross Blue Shield of Massachusetts may require documentation of participation in a structured weight-loss program supervised by a medical professional, and absence of such a program might lead to denial.
  •  

  • Failure to meet prior authorization requirements: Denial can occur if the necessary documentation or prior approval is not obtained or does not justify the necessity of the medication.
  •  

  • Age restrictions: Coverage might be denied if the individual does not fall within the specified age group for which the medication is deemed safe and effective according to their policy.
  •  

  • Usage not in line with FDA-approved guidelines: If the medication is being prescribed for an off-label use that does not align with FDA-approved purposes, coverage may be denied.
  •  

  • Duration of treatment limits exceeded: Coverage may be denied if the prescribed duration for use of the medication exceeds the limits set by the insurance plan.

 

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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 Massachusetts

 

Understand Your Insurance Plan

 

  • Review your Blue Cross Blue Shield of Massachusetts (BCBSMA) health insurance plan documentation to understand your prescription drug coverage.
  •  

  • Check if Phentermine/Topiramate ER (Qsymia) is listed in your plan’s formulary, which is the list of drugs covered by your insurance.

 

Consult with Your Healthcare Provider

 

  • Discuss your need for Phentermine/Topiramate ER (Qsymia) with your healthcare provider. Ensure they understand your medical history and weight management needs.
  •  

  • If your doctor finds it appropriate, obtain a prescription for Qsymia. Ensure the doctor provides any required clinical documentation to support the necessity of this medication.

 

Verify Coverage Prerequisites

 

  • Determine if BCBSMA requires a prior authorization for Qsymia. This step verifies the medical necessity of the prescription before coverage is granted.
  •  

  • Inquire about any specific criteria you must meet, such as Body Mass Index (BMI) thresholds or documentation of previous weight management attempts.

 

Initiate Prior Authorization Process

 

  • Contact your doctor’s office to initiate the prior authorization process. They will work with BCBSMA to submit the necessary paperwork.
  •  

  • Provide your healthcare provider with any additional information or documentation required by BCBSMA during the authorization process.

 

Follow Up on the Authorization

 

  • Regularly check with your healthcare provider and BCBSMA on the status of your prior authorization request.
  •  

  • Be prepared to provide any additional information or clarification if BCBSMA requests further details.

 

Appeal Denied Authorizations

 

  • If your prior authorization is denied, review the reasons for denial with your healthcare provider to determine if you can address those issues.
  •  

  • Consider filing an appeal with BCBSMA, providing additional supportive medical information or a letter from your doctor explaining the necessity for Qsymia.

 

Monitor Your Medication Utilization

 

  • Once approved, follow your healthcare provider’s directions for using Qsymia and adhere to BCBSMA’s utilization guidelines.
  •  

  • Keep records of your prescription refills and any correspondence with BCBSMA regarding your coverage.

 

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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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