Does Harvard Pilgrim Health Care Cover Phentermine/Topiramate ER (Qsymia)

Learn about Harvard Pilgrim's coverage of Qsymia, potential denial reasons, ways to secure coverage, costs without insurance, and FAQs.
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Coverage for Phentermine/Topiramate ER (Qsymia)

 

  • Harvard Pilgrim Health Care typically covers Phentermine/Topiramate ER (Qsymia) for weight management in adults with obesity (a BMI of 30 or more) or overweight individuals (a BMI of 27 or more) with at least one weight-related comorbidity such as hypertension, type 2 diabetes, or dyslipidemia.
  •  

  • Coverage often requires prior authorization, meaning the healthcare provider must demonstrate the medical necessity of the drug.

 

Criteria and Rules

 

  • The patient should have attempted lifestyle modification, such as diet and exercise, prior to medication consideration.
  •  

  • Phentermine/Topiramate ER (Qsymia) should be part of a long-term obesity management strategy, including a reduced-calorie diet and increased physical activity.
  •  

  • Renewal of the prescription may require evidence of positive results, such as weight loss or improved health measures.

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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 Harvard Pilgrim Health Care

 

Verify Your Coverage

 

  • Log into your Harvard Pilgrim Health Care member portal to check if your plan includes prescription drug coverage for weight management medications.
  •  

  • Review the formulary list to see if Phentermine/Topiramate ER (Qsymia) is included. This can usually be found under the 'resources' or 'medications' section.
  •  

  • If you cannot access the information online, contact Harvard Pilgrim's customer service to inquire about drug coverage specifics.

 

Consult Your Healthcare Provider

 

  • Discuss with your healthcare provider the need for Phentermine/Topiramate ER (Qsymia) as part of your treatment plan.
  •  

  • If deemed appropriate, obtain a prescription from your doctor.
  •  

  • Ask your healthcare provider about any necessary documentation or tests needed to qualify for coverage by your insurance plan.

 

Prior Authorization

 

  • Ensure your healthcare provider submits a prior authorization request to Harvard Pilgrim Health Care. This step is often required for medications like Phentermine/Topiramate ER (Qsymia).
  •  

  • Include any necessary medical records and evidence supporting the need for this medication in the prior authorization request.
  •  

  • Follow up with both your doctor and Harvard Pilgrim to ensure the authorization is processed without delay.

 

Review Your Prescription Benefits

 

  • Examine your specific prescription benefits, including co-pays, for medications covered under your plan.
  •  

  • Inquire about any required step therapies or policies that might affect the coverage of Phentermine/Topiramate ER (Qsymia).

 

Appeals Process

 

  • If your prior authorization is denied, initiate an appeal by submitting a request, along with any additional documentation that supports your case.
  •  

  • Work with your healthcare provider to strengthen the appeal, providing detailed medical justifications for the necessity of the drug.

 

Pharmacy Selection

 

  • Locate a preferred or in-network pharmacy that can fill the prescription for Phentermine/Topiramate ER (Qsymia) under your plan's terms.
  •  

  • Confirm with the pharmacy that the medication is covered and verify any out-of-pocket costs you may incur.

 

Track Your Coverage

 

  • Regularly monitor your medication benefits and any changes in coverage terms that could affect Phentermine/Topiramate ER (Qsymia).
  •  

  • Stay informed about any updates from Harvard Pilgrim Health Care regarding formulary changes or new coverage guidelines.

 

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FAQs

Does Harvard Pilgrim Health Care Cover Phentermine/Topiramate ER (Qsymia)

Learn about Harvard Pilgrim's coverage of Qsymia, potential denial reasons, ways to secure coverage, costs without insurance, and FAQs.
Curex allergy drops unboxing

Is Phentermine/Topiramate ER (Qsymia) Covered by Harvard Pilgrim Health Care

 

Coverage for Phentermine/Topiramate ER (Qsymia)

 

  • Harvard Pilgrim Health Care typically covers Phentermine/Topiramate ER (Qsymia) for weight management in adults with obesity (a BMI of 30 or more) or overweight individuals (a BMI of 27 or more) with at least one weight-related comorbidity such as hypertension, type 2 diabetes, or dyslipidemia.
  •  

  • Coverage often requires prior authorization, meaning the healthcare provider must demonstrate the medical necessity of the drug.

 

Criteria and Rules

 

  • The patient should have attempted lifestyle modification, such as diet and exercise, prior to medication consideration.
  •  

  • Phentermine/Topiramate ER (Qsymia) should be part of a long-term obesity management strategy, including a reduced-calorie diet and increased physical activity.
  •  

  • Renewal of the prescription may require evidence of positive results, such as weight loss or improved health measures.

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Harvard Pilgrim Health Care's Approved Criteria for Phentermine/Topiramate ER (Qsymia) Coverage

 

Eligibility Criteria for Qsymia Coverage

 

  • Member must be at least 18 years of age.
  •  

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

  • Alternatively, member must have a BMI of 27 kg/m2 or greater with at least one weight-related comorbidity, such as hypertension, type 2 diabetes mellitus, or dyslipidemia.
  •  

  • Documentation of previous weight management strategies, such as diet and exercise, that have not adequately controlled weight.

 

Trial and Prescription Requirements

 

  • Member must have trialed and failed, or have a contraindication or intolerance to, a preferred formulary alternative in the same therapeutic class unless unavailable.
  •  

  • Prescription must be written by or in consultation with an endocrinologist or a healthcare provider with experience in weight management.

 

Continuation Criteria

 

  • Demonstrated weight loss of at least 5% from baseline when assessed after 12 weeks of therapy.
  •  

  • Documented compliance with the prescribed medication and weight management plan, as assessed by the healthcare provider.

 

Why Harvard Pilgrim Health Care Might Deny Phentermine/Topiramate ER (Qsymia) Coverage

 

Criteria for Non-Coverage of Phentermine/Topiramate ER (Qsymia) by Harvard Pilgrim Health Care

 

  • Harvard Pilgrim Health Care does not cover Phentermine/Topiramate ER (Qsymia) if the patient has not tried or failed to achieve adequate weight loss through lifestyle modifications such as diet and exercise alone.
  •  

  • Coverage is not provided for individuals who are pregnant, planning to become pregnant, or are breastfeeding, due to the potential risks to the fetus or infant.
  •  

  • Patients with a history of cardiovascular disease or uncontrolled hypertension may be denied coverage as the medication can exacerbate these conditions.
  •  

  • Harvard Pilgrim may refuse coverage if there is a history of drug abuse, as Phentermine has potential for abuse and dependency.
  •  

  • The medication is not covered for patients with hyperthyroidism or those with glaucoma, owing to possible adverse effects caused by its use.
  •  

  • If the patient's Body Mass Index (BMI) does not meet the threshold required for obesity or overweight classification according to Harvard Pilgrim’s specific guidelines, coverage is likely denied.
  •  

  • Patients who do not have metabolic syndrome or other weight-related comorbidities that significantly impact health may not be eligible for coverage.
  •  

  • Certain age restrictions may prevent coverage, such as prescriptions for individuals under the age of 18.
  •  

  • Lack of documentation or failure to provide necessary medical records detailing previous weight loss attempts and outcomes can result in non-coverage.
  •  

 

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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 Harvard Pilgrim Health Care

 

Verify Your Coverage

 

  • Log into your Harvard Pilgrim Health Care member portal to check if your plan includes prescription drug coverage for weight management medications.
  •  

  • Review the formulary list to see if Phentermine/Topiramate ER (Qsymia) is included. This can usually be found under the 'resources' or 'medications' section.
  •  

  • If you cannot access the information online, contact Harvard Pilgrim's customer service to inquire about drug coverage specifics.

 

Consult Your Healthcare Provider

 

  • Discuss with your healthcare provider the need for Phentermine/Topiramate ER (Qsymia) as part of your treatment plan.
  •  

  • If deemed appropriate, obtain a prescription from your doctor.
  •  

  • Ask your healthcare provider about any necessary documentation or tests needed to qualify for coverage by your insurance plan.

 

Prior Authorization

 

  • Ensure your healthcare provider submits a prior authorization request to Harvard Pilgrim Health Care. This step is often required for medications like Phentermine/Topiramate ER (Qsymia).
  •  

  • Include any necessary medical records and evidence supporting the need for this medication in the prior authorization request.
  •  

  • Follow up with both your doctor and Harvard Pilgrim to ensure the authorization is processed without delay.

 

Review Your Prescription Benefits

 

  • Examine your specific prescription benefits, including co-pays, for medications covered under your plan.
  •  

  • Inquire about any required step therapies or policies that might affect the coverage of Phentermine/Topiramate ER (Qsymia).

 

Appeals Process

 

  • If your prior authorization is denied, initiate an appeal by submitting a request, along with any additional documentation that supports your case.
  •  

  • Work with your healthcare provider to strengthen the appeal, providing detailed medical justifications for the necessity of the drug.

 

Pharmacy Selection

 

  • Locate a preferred or in-network pharmacy that can fill the prescription for Phentermine/Topiramate ER (Qsymia) under your plan's terms.
  •  

  • Confirm with the pharmacy that the medication is covered and verify any out-of-pocket costs you may incur.

 

Track Your Coverage

 

  • Regularly monitor your medication benefits and any changes in coverage terms that could affect Phentermine/Topiramate ER (Qsymia).
  •  

  • Stay informed about any updates from Harvard Pilgrim Health Care regarding formulary changes or new coverage guidelines.

 

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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?

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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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