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Does CareFirst BlueCross BlueShield Cover Phentermine/Topiramate ER (Qsymia)

Explore if CareFirst covers Qsymia, reasons for potential denial, ways to gain coverage, costs without insurance, and FAQs in our comprehensive guide.

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Coverage for Phentermine/Topiramate ER (Qsymia)

CareFirst BlueCross BlueShield may cover Phentermine/Topiramate ER (Qsymia) for patients diagnosed with obesity-related health conditions.

Coverage often requires that the patient has a Body Mass Index (BMI) of 30 or greater, or a BMI of 27 with at least one weight-related health issue, such as hypertension or type 2 diabetes.

Basic Rules and Criteria

Prior authorization is typically necessary. Physicians must submit documentation proving the medical necessity of the treatment.

Patients might need to demonstrate previous unsuccessful weight management attempts through lifestyle modifications.

Continued coverage may require that the patient shows adequate response in weight loss within a specified period.

Physicians should routinely monitor and report the patient's progress as a condition for ongoing coverage.

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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 CareFirst BlueCross BlueShield

Start by Reviewing Your Insurance Plan

Visit the CareFirst BlueCross BlueShield website and log into your account to access your insurance plan information. Look for the section that details prescription drug coverage.

Identify if there is an included formulary list to check if Phentermine/Topiramate ER (Qsymia) is part of the approved medications.

Consult with Your Healthcare Provider

Discuss your interest in Phentermine/Topiramate ER (Qsymia) with your doctor. Confirm that this medication is medically necessary for your condition and that it’s the right option for you.

Your doctor may need to provide documentation that justifies the prescription of Phentermine/Topiramate ER under your current health condition.

Gather Necessary Documentation

Ask your healthcare provider to supply any necessary documentation, such as a Letter of Medical Necessity, to strengthen your case for insurance coverage. This letter should include your diagnosis, treatment history, and why Qsymia is favored over other treatments.

Check if you need any specific forms required by CareFirst BlueCross BlueShield to process a drug prior authorization.

Contact CareFirst BlueCross BlueShield

Call the member services number on your insurance card to inquire about the necessary steps to obtain coverage for Phentermine/Topiramate ER. Keep notes of your conversation for your records.

You might be directed to their pharmacy department or to fill out a pre-authorization request. Confirm the details required for such a submission.

Submit a Prior Authorization Request

If a prior authorization is required, work with your doctor to complete the necessary forms. Ensure everything is filled out correctly and that you have included all supporting documents.

Submit the complete prior authorization form through the methods accepted by CareFirst BlueCross BlueShield, such as fax, mail, or online submission.

Follow Up on Your Request

After submission, follow up with CareFirst BlueCross BlueShield to confirm receipt of your authorization request. Keep track of reference numbers or any communication details.

Inquire about the typical processing time and next steps. Ask how you will be informed of the decision.

Appeal if Necessary

If your prior authorization for Phentermine/Topiramate ER is denied, review the reasons provided by CareFirst BlueCross BlueShield. This information should guide your appeal.

File an appeal with any additional documentation or clarification needed to support your case. Enlist your doctor’s help if necessary, as provider input can be critical in appeals.

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FAQs

Does CareFirst BlueCross BlueShield Cover Phentermine/Topiramate ER (Qsymia)

Explore if CareFirst covers Qsymia, reasons for potential denial, ways to gain coverage, costs without insurance, and FAQs in our comprehensive guide.

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Is Phentermine/Topiramate ER (Qsymia) Covered by CareFirst BlueCross BlueShield

Coverage for Phentermine/Topiramate ER (Qsymia)

CareFirst BlueCross BlueShield may cover Phentermine/Topiramate ER (Qsymia) for patients diagnosed with obesity-related health conditions.

Coverage often requires that the patient has a Body Mass Index (BMI) of 30 or greater, or a BMI of 27 with at least one weight-related health issue, such as hypertension or type 2 diabetes.

Basic Rules and Criteria

Prior authorization is typically necessary. Physicians must submit documentation proving the medical necessity of the treatment.

Patients might need to demonstrate previous unsuccessful weight management attempts through lifestyle modifications.

Continued coverage may require that the patient shows adequate response in weight loss within a specified period.

Physicians should routinely monitor and report the patient's progress as a condition for ongoing coverage.

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CareFirst BlueCross BlueShield's Approved Criteria for Phentermine/Topiramate ER (Qsymia) Coverage

Criteria for Phentermine/Topiramate ER (Qsymia) 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, indicating obesity.

A diagnosis of overweight with a BMI of 27 kg/m² or greater is required along with at least one weight-related comorbidity, such as hypertension, type 2 diabetes mellitus, or dyslipidemia.

There must be documented evidence that the patient has tried previous weight management therapies, including lifestyle intervention programs like diet and exercise, but achieved inadequate weight loss or found it unsustainable.

The prescribing healthcare provider must provide a clear treatment plan that includes a comprehensive lifestyle intervention program aimed at long-term weight management beyond pharmacotherapy.

Monitoring of treatment efficacy and safety is essential, requiring periodic follow-ups to assess response to the medication and any potential side effects.

Documentation must illustrate a multidisciplinary approach involving healthcare professionals such as dieticians, behavioral therapists, or physical therapists to support weight management efforts.

Continuation of therapy must demonstrate a minimum weight loss of 3% in the first 12 weeks of treatment to justify ongoing use of the medication.

Why CareFirst BlueCross BlueShield Might Deny Phentermine/Topiramate ER (Qsymia) Coverage

Reasons for Denial of Phentermine/Topiramate ER (Qsymia) Coverage by CareFirst BlueCross BlueShield

Non-compliance with FDA-Approved Indications: If the prescribed use of Phentermine/Topiramate ER (Qsymia) falls outside of the FDA-approved indications, CareFirst BlueCross BlueShield might deny coverage.

Lack of Documented Weight-Loss Attempts: Patients who cannot provide documentation of previous unsuccessful weight-loss attempts through diet and exercise may face denial of coverage.

Failure to Meet BMI Requirements: Coverage could be denied if the patient's Body Mass Index (BMI) does not meet CareFirst's specified minimum, often requiring a BMI of 30 or greater, or 27 or greater with comorbid conditions.

Non-adherence to Prescription Drug Plan: If Phentermine/Topiramate ER (Qsymia) is not included in the patient's specific prescription drug plan or formulary, coverage might be denied.

Lack of Required Prior Authorization: Failure to obtain the necessary prior authorization from CareFirst BlueCross BlueShield before obtaining Phentermine/Topiramate ER (Qsymia) can result in denial of coverage.

Absence of Medical Necessity: Denial may occur if CareFirst determines that the prescription is not medically necessary according to their clinical guidelines or criteria.

Age Restrictions: Coverage could be restricted for patients who do not fall within the approved age range specified by CareFirst BlueCross BlueShield policies.

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How Much Does Phentermine/Topiramate ER (Qsymia) Cost without Insurance?

Cost of Phentermine/Topiramate ER (Qsymia) Without Insurance

The average retail price for Phentermine/Topiramate ER (Qsymia), a medication typically prescribed for weight loss, ranges from $120 to $240 for a 30-day supply, depending on the pharmacy and location.

Prices may vary slightly due to specific factors such as dosage strength, with differing costs for varying dosages like 3.75 mg/23 mg, 7.5 mg/46 mg, 11.25 mg/69 mg, and 15 mg/92 mg.

Discount programs or pharmacy coupons might offer lower prices, potentially reducing the cost to as low as $100 for a monthly supply. It is advisable for patients to explore these options for financial relief.

Some pharmacies provide price matching, which can be helpful in securing the best available price without insurance.

Patients should check for any available manufacturer's savings programs or patient assistance plans that might further aid in reducing out-of-pocket costs.

Clinical Support

Our team is here to help!

Dr. Neeta Ogden, MD

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

Dr. Ravi Patel, VP Telemedicine

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

Kayla Mardaga, NP

How to Get Phentermine/Topiramate ER (Qsymia) Coverage with CareFirst BlueCross BlueShield

Start by Reviewing Your Insurance Plan

Visit the CareFirst BlueCross BlueShield website and log into your account to access your insurance plan information. Look for the section that details prescription drug coverage.

Identify if there is an included formulary list to check if Phentermine/Topiramate ER (Qsymia) is part of the approved medications.

Consult with Your Healthcare Provider

Discuss your interest in Phentermine/Topiramate ER (Qsymia) with your doctor. Confirm that this medication is medically necessary for your condition and that it’s the right option for you.

Your doctor may need to provide documentation that justifies the prescription of Phentermine/Topiramate ER under your current health condition.

Gather Necessary Documentation

Ask your healthcare provider to supply any necessary documentation, such as a Letter of Medical Necessity, to strengthen your case for insurance coverage. This letter should include your diagnosis, treatment history, and why Qsymia is favored over other treatments.

Check if you need any specific forms required by CareFirst BlueCross BlueShield to process a drug prior authorization.

Contact CareFirst BlueCross BlueShield

Call the member services number on your insurance card to inquire about the necessary steps to obtain coverage for Phentermine/Topiramate ER. Keep notes of your conversation for your records.

You might be directed to their pharmacy department or to fill out a pre-authorization request. Confirm the details required for such a submission.

Submit a Prior Authorization Request

If a prior authorization is required, work with your doctor to complete the necessary forms. Ensure everything is filled out correctly and that you have included all supporting documents.

Submit the complete prior authorization form through the methods accepted by CareFirst BlueCross BlueShield, such as fax, mail, or online submission.

Follow Up on Your Request

After submission, follow up with CareFirst BlueCross BlueShield to confirm receipt of your authorization request. Keep track of reference numbers or any communication details.

Inquire about the typical processing time and next steps. Ask how you will be informed of the decision.

Appeal if Necessary

If your prior authorization for Phentermine/Topiramate ER is denied, review the reasons provided by CareFirst BlueCross BlueShield. This information should guide your appeal.

File an appeal with any additional documentation or clarification needed to support your case. Enlist your doctor’s help if necessary, as provider input can be critical in appeals.

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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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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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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. 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?

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.

Can you prescribe Ozempic®* or Wegovy®*?

Our providers focus on personalized medications and dosages that aren’t commercially available at your local pharmacy. We don’t prescribe Ozempic®* or Wegovy®.* We may prescribe treatments containing compounded semaglutide or tirzepatide. 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.

Does CareFirst BlueCross BlueShield Cover Phentermine/Topiramate ER (Qsymia)

Explore if CareFirst covers Qsymia, reasons for potential denial, ways to gain coverage, costs without insurance, and FAQs in our comprehensive guide.

Achieve Your Goals Faster with Curex