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

Explore Blue Cross of Idaho's coverage for Qsymia, learn why it may be denied, tips to secure coverage, costs without insurance, and FAQs.
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Coverage for Phentermine/Topiramate ER (Qsymia)

 

  • Blue Cross of Idaho may cover Qsymia under certain conditions primarily related to weight management.
  •  

  • Coverage is typically considered for patients classified as obese (BMI ≥ 30 kg/m²) or those overweight (BMI ≥ 27 kg/m²) with weight-related comorbidities.
  •  

  • An individual must have attempted weight loss through lifestyle modifications under physician guidance before medication approval.

 

Criteria for Approval

 

  • A prior authorization process is often required, ensuring that the patient meets specified criteria.
  •  

  • Completed documentation from the healthcare provider, outlining medical necessity and previous weight loss attempts, may be necessary.
  •  

  • Regular follow-up and continued usage evaluation are likely needed for sustained 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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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 of Idaho

 

Verify Coverage and Benefits

 

  • Log in to your Blue Cross of Idaho member account online or call the customer service number on the back of your insurance card.
  •  

  • Inquire whether Phentermine/Topiramate ER (Qsymia) is covered under your current plan's formulary and what tier it falls under.
  •  

  • Ask if prior authorization is needed and gather any necessary forms or procedures required by Blue Cross of Idaho for medication approval.

 

Consult Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss the possibility of using Qsymia for weight management, ensuring it's appropriate for your health needs.
  •  

  • Request that your healthcare provider write a prescription for Phentermine/Topiramate ER (Qsymia) if deemed suitable for your treatment plan.
  •  

  • Ask your provider to complete any prior authorization forms required by Blue Cross of Idaho.

 

Submit Prior Authorization Request

 

  • Complete and submit the prior authorization form to Blue Cross of Idaho through their designated process, typically done by your healthcare provider’s office.
  •  

  • Provide any necessary documentation of medical necessity, as described by your provider, to support the use of Qsymia.
  •  

  • Follow up with the insurance company to ensure the form and any additional required documentation have been received.

 

Monitor Request Status

 

  • Keep track of your prior authorization request status. Blue Cross of Idaho may take several days to process the request.
  •  

  • Contact your insurer periodically to inquire about the status, ensuring that nothing further is needed from your end.
  •  

  • Notify your healthcare provider if additional documentation or clarification is required from them during the review process.

 

Understand the Decision

 

  • If approved, confirm with your pharmacy that they have received the authorization and understand how to fill your prescription under the coverage terms.
  •  

  • If denied, review the denial letter for specific reasons and consider appealing the decision if appropriate. Coordinate with your healthcare provider to address reasons for denial and compile additional supporting documentation for the appeal.

 

Consider Alternatives if Necessary

 

  • If coverage is denied and the appeal is unsuccessful, discuss alternative medications or treatment options with your healthcare provider.
  •  

  • Investigate patient assistance programs offered by the drug manufacturer that may reduce costs for Phentermine/Topiramate ER (Qsymia).

 

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

Explore Blue Cross of Idaho's coverage for Qsymia, learn why it may be denied, tips to secure coverage, costs without insurance, and FAQs.
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Is Phentermine/Topiramate ER (Qsymia) Covered by Blue Cross of Idaho

 

Coverage for Phentermine/Topiramate ER (Qsymia)

 

  • Blue Cross of Idaho may cover Qsymia under certain conditions primarily related to weight management.
  •  

  • Coverage is typically considered for patients classified as obese (BMI ≥ 30 kg/m²) or those overweight (BMI ≥ 27 kg/m²) with weight-related comorbidities.
  •  

  • An individual must have attempted weight loss through lifestyle modifications under physician guidance before medication approval.

 

Criteria for Approval

 

  • A prior authorization process is often required, ensuring that the patient meets specified criteria.
  •  

  • Completed documentation from the healthcare provider, outlining medical necessity and previous weight loss attempts, may be necessary.
  •  

  • Regular follow-up and continued usage evaluation are likely needed for sustained coverage.

 

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

 

Eligibility Criteria for Phentermine/Topiramate ER (Qsymia) Coverage

 

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

  • If the patient's BMI is between 27 kg/m2 and 29.9 kg/m2, they must have at least one weight-related comorbidity, such as hypertension, type 2 diabetes, or dyslipidemia.
  •  

  • The patient must be at least 18 years of age and possess a valid prescription from a licensed healthcare provider.
  •  

  • Demonstration of previous unsuccessful attempts to lose weight through lifestyle modifications, such as diet and exercise, must be documented in the patient's medical records.
  •  

  • The prescribing healthcare provider should have a treatment plan in place that includes continuous monitoring of weight and metabolic health metrics.

 

Initial Evaluation Requirements

 

  • Baseline assessment must include a comprehensive medical evaluation addressing any secondary causes of obesity and assessing the risk factors associated with obesity.
  •  

  • Documentation of a detailed medical history including family history, previous weight loss interventions, and current medications, which might affect weight.
  •  

  • The patient should have demonstrated a commitment to lifestyle modifications as part of their weight loss plan for a period deemed sufficient by their healthcare provider, generally for at least 6 months.

 

Continuation of Therapy Requirements

 

  • Initially approved coverage duration is typically for 3 months, after which continuation requires evidence of weight loss of at least 3% of baseline body weight.
  •  

  • For therapy extension beyond the initial period, records must show that the patient has benefited from Qsymia in terms of weight loss and that there is no severe adverse event associated with its use.
  •  

  • Continuous engagement in lifestyle changes, documented through regular consultations with the healthcare provider, is required for ongoing coverage.

 

Healthcare Provider's Responsibilities

 

  • Regularly assess blood pressure and heart rate as part of monitoring cardiovascular health during Qsymia treatment.
  •  

  • Track the patient's progress every 4 to 6 weeks during the initial treatment phase, ensuring treatment compliance and effectiveness.
  •  

  • Adjust or discontinue therapy depending on clinical assessment and patient's progress.

 

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

 

Reasons for Non-Coverage of Phentermine/Topiramate ER (Qsymia)

 

  • Patient has not met the specific medical criteria or diagnosis required for coverage.
  •  

  • The prescription has not been authorized or prescribed by an in-network provider, which is a requirement for certain medications.
  •  

  • There is an absence of comprehensive documentation evidencing previous attempts of weight loss through diet and exercise.
  •  

  • The patient lacks a documented history of obesity-related conditions that are often necessary to justify the use of Qsymia.
  •  

  • The medication is deemed to be experimental, investigational, or not medically necessary for the condition presented.
  •  

  • Qsymia is being prescribed for off-label uses that have not been approved by Blue Cross of Idaho's medical guidelines.
  •  

  • The patient does not meet the Body Mass Index (BMI) requirements or other health measurement criteria specified by the insurer.
  •  

  • Coverage was requested without an adequate trial and failure of other weight loss medications as part of the treatment plan.
  •  

  • The patient's existing health conditions or medication interactions present contraindications for the use of Phentermine/Topiramate ER.
  •  

 

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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 of Idaho

 

Verify Coverage and Benefits

 

  • Log in to your Blue Cross of Idaho member account online or call the customer service number on the back of your insurance card.
  •  

  • Inquire whether Phentermine/Topiramate ER (Qsymia) is covered under your current plan's formulary and what tier it falls under.
  •  

  • Ask if prior authorization is needed and gather any necessary forms or procedures required by Blue Cross of Idaho for medication approval.

 

Consult Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss the possibility of using Qsymia for weight management, ensuring it's appropriate for your health needs.
  •  

  • Request that your healthcare provider write a prescription for Phentermine/Topiramate ER (Qsymia) if deemed suitable for your treatment plan.
  •  

  • Ask your provider to complete any prior authorization forms required by Blue Cross of Idaho.

 

Submit Prior Authorization Request

 

  • Complete and submit the prior authorization form to Blue Cross of Idaho through their designated process, typically done by your healthcare provider’s office.
  •  

  • Provide any necessary documentation of medical necessity, as described by your provider, to support the use of Qsymia.
  •  

  • Follow up with the insurance company to ensure the form and any additional required documentation have been received.

 

Monitor Request Status

 

  • Keep track of your prior authorization request status. Blue Cross of Idaho may take several days to process the request.
  •  

  • Contact your insurer periodically to inquire about the status, ensuring that nothing further is needed from your end.
  •  

  • Notify your healthcare provider if additional documentation or clarification is required from them during the review process.

 

Understand the Decision

 

  • If approved, confirm with your pharmacy that they have received the authorization and understand how to fill your prescription under the coverage terms.
  •  

  • If denied, review the denial letter for specific reasons and consider appealing the decision if appropriate. Coordinate with your healthcare provider to address reasons for denial and compile additional supporting documentation for the appeal.

 

Consider Alternatives if Necessary

 

  • If coverage is denied and the appeal is unsuccessful, discuss alternative medications or treatment options with your healthcare provider.
  •  

  • Investigate patient assistance programs offered by the drug manufacturer that may reduce costs for Phentermine/Topiramate ER (Qsymia).

 

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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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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.

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.

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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.

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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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