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

Explore Blue Cross Blue Shield of Texas coverage for Qsymia, reasons for denial, tips for approval, costs without insurance, and FAQs in our comprehensive guide.
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Coverage for Phentermine/Topiramate ER (Qsymia)

 

  • Blue Cross Blue Shield of Texas may cover Phentermine/Topiramate ER (Qsymia) as part of their weight management or obesity treatment programs, depending on the individual's specific plan.
  •  

  • Insurance coverage for Qsymia often requires a prior authorization, which means your healthcare provider must certify that the medication is medically necessary.
  •  

 

Eligibility Criteria

 

  • To be eligible for coverage, a patient typically needs to have a body mass index (BMI) indicating obesity or a weight-related condition such as type 2 diabetes or hypertension.
  •  

  • Patients are generally required to have attempted weight loss through diet and exercise without sufficient success before coverage is approved.
  •  

 

Requirements for Coverage

 

  • Continued coverage may require documentation of weight loss progress, adherence to prescribed treatment plans, and regular follow-up evaluations.
  •  

  • Always consult with your insurance to confirm specific coverage details, as these can vary based on individual plans and policy changes.

 

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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.

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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 Blue Cross Blue Shield of Texas

 

Verify Your Insurance Benefits

 

  • Contact Blue Cross Blue Shield of Texas (BCBSTX) customer service to verify your plan's specific coverage for Phentermine/Topiramate ER (Qsymia). Obtain information on any prerequisites for coverage or necessary documentation.
  •  

  • Review your policy details online through the BCBSTX member portal to understand the coverage specifics for weight-loss medications.

 

Consult Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss whether Phentermine/Topiramate ER (Qsymia) is an appropriate medication for you and obtain a prescription if deemed necessary.
  •  

  • Request that your healthcare provider submits a prior authorization request to BCBSTX if required by your insurance plan for this medication.

 

Submit Necessary Documentation

 

  • If a prior authorization is needed, ensure that your healthcare provider provides all necessary medical records and documentation to BCBSTX to support the necessity of the medication.
  •  

  • Confirm with your provider that they have completed and sent all forms required for prior authorization to reduce processing delays.

 

Follow Up with Insurance

 

  • Contact BCBSTX to confirm receipt of the prior authorization request and inquire about the expected timeline for a decision.
  •  

  • If needed, follow up periodically to check the status of your approval, ensuring that there are no additional documentation requirements left unattended.

 

Explore Appeals Process If Denied

 

  • If your prior authorization is denied, familiarize yourself with BCBSTX’s appeals process as detailed on their website or through customer service.
  •  

  • Work with your healthcare provider to submit an appeal with additional supporting documentation that highlights the necessity of Phentermine/Topiramate ER for your treatment plan.

 

Utilize Savings Programs

 

  • Investigate any manufacturer coupon or savings card programs for Qsymia that could help reduce out-of-pocket expenses, particularly if there are delays or issues with insurance coverage.
  •  

  • Consult with your pharmacy to identify any additional savings programs or discounts available to you.

 

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FAQs

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

Explore Blue Cross Blue Shield of Texas coverage for Qsymia, reasons for denial, tips for approval, costs without insurance, and FAQs in our comprehensive guide.
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Is Phentermine/Topiramate ER (Qsymia) Covered by Blue Cross Blue Shield of Texas

 

Coverage for Phentermine/Topiramate ER (Qsymia)

 

  • Blue Cross Blue Shield of Texas may cover Phentermine/Topiramate ER (Qsymia) as part of their weight management or obesity treatment programs, depending on the individual's specific plan.
  •  

  • Insurance coverage for Qsymia often requires a prior authorization, which means your healthcare provider must certify that the medication is medically necessary.
  •  

 

Eligibility Criteria

 

  • To be eligible for coverage, a patient typically needs to have a body mass index (BMI) indicating obesity or a weight-related condition such as type 2 diabetes or hypertension.
  •  

  • Patients are generally required to have attempted weight loss through diet and exercise without sufficient success before coverage is approved.
  •  

 

Requirements for Coverage

 

  • Continued coverage may require documentation of weight loss progress, adherence to prescribed treatment plans, and regular follow-up evaluations.
  •  

  • Always consult with your insurance to confirm specific coverage details, as these can vary based on individual plans and policy changes.

 

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

 

Eligibility for Treatment

 

  • The patient must be 18 years or older.
  • The individual should have a documented diagnosis of obesity with a Body Mass Index (BMI) of 30 kg/m² or greater.
  • Alternatively, the patient may have a BMI of 27 kg/m² or greater with at least one weight-related comorbidity such as hypertension, type 2 diabetes, or dyslipidemia.

 

Previous Weight Management Attempts

 

  • The patient must have attempted weight management strategies through a comprehensive weight control program that includes a calorie-reduced diet and increased physical activity for at least six months prior to initiation of Phentermine/Topiramate ER (Qsymia).
  • Documentation of these efforts should be provided and verified by the healthcare provider.

 

Medication Criteria

 

  • There must be no contraindications to Phentermine/Topiramate ER (Qsymia) use, as determined by the prescribing healthcare provider.
  • The patient must be evaluated for potential interactions with other ongoing medications and treatments.
  • The healthcare provider should perform a thorough assessment to ensure the patient understands the potential side effects and required lifestyle changes for the medication to be effective.

 

Monitoring and Follow-up

 

  • Coverage requires periodic assessment by the healthcare provider to monitor progress, side effects, and effectiveness of the treatment.
  • Continued coverage is contingent upon documented weight reduction as determined by the healthcare provider, noted at intervals specified by the provider.
  • The provider should reassess the appropriateness of continued therapy if the patient has not lost at least 3% of baseline body weight after 12 weeks on the medication.

 

Documentation and Prior Authorization

 

  • Pre-approval through Blue Cross Blue Shield of Texas may be necessary, requiring detailed documentation supporting the medical necessity of Phentermine/Topiramate ER (Qsymia) based on established criteria.
  • All medical records, including baseline and follow-up BMI measurements, should be included in the submission for coverage consideration.

 

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

 

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

 

  • The medication is requested for weight loss when not clinically appropriate, such as not meeting BMI requirements or the absence of weight-related comorbidities.
  •  

  • Patient does not meet the age criteria specified in the policy. The medication is generally not covered for patients outside the adult age range unless stated otherwise.
  •  

  • Use of phentermine/topiramate ER (Qsymia) for non-medically necessary or experimental purposes that are not supported by clinical guidelines.
  •  

  • Patient has a contraindication for the use of the medication, which is specified in clinical policy or guidelines, such as pregnancy, glaucoma, or hyperthyroidism.
  •  

  • Failure to demonstrate previous unsuccessful attempts at weight loss using more conservative methodologies, such as lifestyle modification or other weight management medications.
  •  

  • The prescription does not follow the required prior authorization or step therapy protocols. This may include attempting other preferred medications prior to approval.
  •  

  • Coverage is denied if the request does not include the necessary documentation from a healthcare provider illustrating medical necessity.
  •  

 

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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 Texas

 

Verify Your Insurance Benefits

 

  • Contact Blue Cross Blue Shield of Texas (BCBSTX) customer service to verify your plan's specific coverage for Phentermine/Topiramate ER (Qsymia). Obtain information on any prerequisites for coverage or necessary documentation.
  •  

  • Review your policy details online through the BCBSTX member portal to understand the coverage specifics for weight-loss medications.

 

Consult Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss whether Phentermine/Topiramate ER (Qsymia) is an appropriate medication for you and obtain a prescription if deemed necessary.
  •  

  • Request that your healthcare provider submits a prior authorization request to BCBSTX if required by your insurance plan for this medication.

 

Submit Necessary Documentation

 

  • If a prior authorization is needed, ensure that your healthcare provider provides all necessary medical records and documentation to BCBSTX to support the necessity of the medication.
  •  

  • Confirm with your provider that they have completed and sent all forms required for prior authorization to reduce processing delays.

 

Follow Up with Insurance

 

  • Contact BCBSTX to confirm receipt of the prior authorization request and inquire about the expected timeline for a decision.
  •  

  • If needed, follow up periodically to check the status of your approval, ensuring that there are no additional documentation requirements left unattended.

 

Explore Appeals Process If Denied

 

  • If your prior authorization is denied, familiarize yourself with BCBSTX’s appeals process as detailed on their website or through customer service.
  •  

  • Work with your healthcare provider to submit an appeal with additional supporting documentation that highlights the necessity of Phentermine/Topiramate ER for your treatment plan.

 

Utilize Savings Programs

 

  • Investigate any manufacturer coupon or savings card programs for Qsymia that could help reduce out-of-pocket expenses, particularly if there are delays or issues with insurance coverage.
  •  

  • Consult with your pharmacy to identify any additional savings programs or discounts available to you.

 

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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.

Each pharmacy in our network undergoes rigorous third-party testing through FDA and DEA certified labs. These tests focus on four key elements, ensuring both safety and efficacy for our treatments.

Phentermine/Topiramate ER (Qsymia) FAQ

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

 

Common Side Effects of Qsymia

 

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

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

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

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

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

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

How effective is Qsymia for weight loss?

 

Effectiveness of Qsymia

 

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

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

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

 

Considerations

 

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

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

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

 

Can Qsymia be taken long-term for weight management?

 

Long-term Use of Qsymia

 

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

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

 

Monitoring and Safety

 

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

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

 

Continuing Treatment

 

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

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

 

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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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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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