Does Medica Cover Phentermine/Topiramate ER (Qsymia)

Discover if Medica covers Phentermine/Topiramate ER, reasons for denial, obtaining coverage, costs without insurance, and FAQs.
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Medica Coverage for Phentermine/Topiramate ER (Qsymia)

 

  • Medica may cover Qsymia for patients meeting specific criteria aimed at weight management.
  •  

  • The medication is typically covered for patients who have a Body Mass Index (BMI) ≥ 30 kg/m² or a BMI ≥ 27 kg/m² with related conditions like hypertension, type 2 diabetes, or dyslipidemia.
  •  

  • Patients may need to demonstrate that previous weight loss efforts using diet and exercise were unsuccessful.
  •  

  • Prior authorization is often required, involving documentation of the patient's medical history and weight management efforts.
  •  

  • Coverage rules and criteria can vary based on the specific Medica plan, and patients should consult their plan's formulary and guidelines or contact Medica directly for precise information.

 

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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 Medica

 

Research Your Benefits

 

  • Contact Medica customer service through the phone number on your insurance card to inquire about your current prescription drug plan.
  •  

  • Ask specifically if Phentermine/Topiramate ER (Qsymia) is covered under your plan and what tier it is categorized under.
  •  

  • Verify if there are any specific prerequisites, such as prior authorizations, quantity limits, or step therapy, to cover Qsymia.

 

Consult Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss the possibility of starting Qsymia treatment and its necessity for your health.
  •  

  • Ensure your healthcare provider is equipped to provide the necessary documentation or justification that Medica might require.
  •  

  • Request your provider to submit a prior authorization request to Medica if needed.

 

Prepare Documentation

 

  • Gather any supporting medical records that indicate your need for Qsymia. This might include past treatments, diagnosis, and a recommendation from your healthcare provider.
  •  

  • Be prepared to share your weight history and any past struggles with weight management, which might support the need for this medication.

 

Submit a Prior Authorization Request

 

  • Work with your healthcare provider to submit a prior authorization request to Medica, if this is a requirement for Qsymia.
  •  

  • Include all necessary documentation and ensure the request is detailed and fully justifies the necessity of the medication.
  •  

  • Keep in contact with your provider to confirm that the request has been sent and follow up with Medica to track the status of your request.

 

Explore Appeals if Denied

 

  • If coverage is initially denied, work with your healthcare provider to prepare an appeal.
  •  

  • Gather additional documentation or a letter of medical necessity from your healthcare provider to strengthen your appeal.
  •  

  • Submit the appeal to Medica following their specified procedures and keep in close communication to understand any further requirements.

 

Consider Additional Help

 

  • If complications continue, reach out to patient advocacy services or Medica's member assistance for guidance on securing coverage.
  •  

  • Investigate manufacturer coupons or assistance programs that may provide financial support if insurance coverage remains unavailable.
  •  

  • Explore alternative insurance plans during open enrollment periods that may offer better coverage for Qsymia.

 

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FAQs

Does Medica Cover Phentermine/Topiramate ER (Qsymia)

Discover if Medica covers Phentermine/Topiramate ER, reasons for denial, obtaining coverage, costs without insurance, and FAQs.
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Is Phentermine/Topiramate ER (Qsymia) Covered by Medica

 

Medica Coverage for Phentermine/Topiramate ER (Qsymia)

 

  • Medica may cover Qsymia for patients meeting specific criteria aimed at weight management.
  •  

  • The medication is typically covered for patients who have a Body Mass Index (BMI) ≥ 30 kg/m² or a BMI ≥ 27 kg/m² with related conditions like hypertension, type 2 diabetes, or dyslipidemia.
  •  

  • Patients may need to demonstrate that previous weight loss efforts using diet and exercise were unsuccessful.
  •  

  • Prior authorization is often required, involving documentation of the patient's medical history and weight management efforts.
  •  

  • Coverage rules and criteria can vary based on the specific Medica plan, and patients should consult their plan's formulary and guidelines or contact Medica directly for precise information.

 

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Medica's Approved Criteria for Phentermine/Topiramate ER (Qsymia) Coverage

 

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

 

  • Patients must be 18 years of age or older.
  •  

  • Diagnosis of obesity. Obesity is defined as a body mass index (BMI) of 30 kg/m² or greater.
  •  

  • For patients with a BMI of 27 kg/m² to less than 30 kg/m², they must have at least one weight-related comorbidity. Examples include hypertension, type 2 diabetes, or dyslipidemia.
  •  

  • Evidence of previous unsuccessful attempts to lose weight through non-pharmacologic interventions such as diet, exercise, and behavioral modification.
  •  

  • The prescriber must submit documentation of metabolic work-up including baseline laboratory values and cardiovascular evaluations as needed.
  •  

  • Patients should not be on any other concurrent weight loss medications during the treatment with Phentermine/Topiramate ER (Qsymia).
  •  

 

Criteria for Continuation of Coverage

 

  • Continued use is approved if there is physician-documented weight loss of at least 3% within 12 weeks from initiation.
  •  

  • Patients must exhibit adherence to lifestyle changes alongside pharmacotherapy. This includes dietary modifications and increased physical activity.
  •  

  • Continuous assessment by the healthcare provider ensuring no significant adverse effects are present.
  •  

  • Regular follow-ups for retesting target comorbid conditions to ensure optimal management in conjunction with weight loss.
  •  

 

Additional Considerations

 

  • Special consideration for those with stabilized cardiovascular diseases. Patients with uncontrolled cardiovascular conditions should not receive coverage under these criteria.
  •  

  • Close monitoring for pregnant patients or females of reproductive potential, including evaluation of possible risks associated with drug use during pregnancy.
  •  

 

Why Medica Might Deny Phentermine/Topiramate ER (Qsymia) Coverage

 

Exclusion Criteria

 

  • Medica may not cover Phentermine/Topiramate ER (Qsymia) if the patient does not meet specific Body Mass Index (BMI) criteria. This includes patients with a BMI below the threshold set for obesity-related drug therapy.
  •  

  • Coverage may be denied for individuals who have not tried and documented unsuccessful weight loss through diet and exercise prior to starting the medication.
  •  

  • Patients with certain medical conditions, such as glaucoma or hyperthyroidism, may be excluded from coverage due to contraindications associated with Phentermine/Topiramate ER.
  •  

  • If the prescription of Qsymia is for purposes other than weight management, such as off-label use, coverage might be denied by Medica.
  •  

  • Phentermine/Topiramate ER may not be covered for individuals who are pregnant or planning to become pregnant, due to potential risks associated with the medication.
  •  

  • Patients who are using certain other medications or supplements that may interact negatively with Qsymia might face denial of 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 Medica

 

Research Your Benefits

 

  • Contact Medica customer service through the phone number on your insurance card to inquire about your current prescription drug plan.
  •  

  • Ask specifically if Phentermine/Topiramate ER (Qsymia) is covered under your plan and what tier it is categorized under.
  •  

  • Verify if there are any specific prerequisites, such as prior authorizations, quantity limits, or step therapy, to cover Qsymia.

 

Consult Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss the possibility of starting Qsymia treatment and its necessity for your health.
  •  

  • Ensure your healthcare provider is equipped to provide the necessary documentation or justification that Medica might require.
  •  

  • Request your provider to submit a prior authorization request to Medica if needed.

 

Prepare Documentation

 

  • Gather any supporting medical records that indicate your need for Qsymia. This might include past treatments, diagnosis, and a recommendation from your healthcare provider.
  •  

  • Be prepared to share your weight history and any past struggles with weight management, which might support the need for this medication.

 

Submit a Prior Authorization Request

 

  • Work with your healthcare provider to submit a prior authorization request to Medica, if this is a requirement for Qsymia.
  •  

  • Include all necessary documentation and ensure the request is detailed and fully justifies the necessity of the medication.
  •  

  • Keep in contact with your provider to confirm that the request has been sent and follow up with Medica to track the status of your request.

 

Explore Appeals if Denied

 

  • If coverage is initially denied, work with your healthcare provider to prepare an appeal.
  •  

  • Gather additional documentation or a letter of medical necessity from your healthcare provider to strengthen your appeal.
  •  

  • Submit the appeal to Medica following their specified procedures and keep in close communication to understand any further requirements.

 

Consider Additional Help

 

  • If complications continue, reach out to patient advocacy services or Medica's member assistance for guidance on securing coverage.
  •  

  • Investigate manufacturer coupons or assistance programs that may provide financial support if insurance coverage remains unavailable.
  •  

  • Explore alternative insurance plans during open enrollment periods that may offer better coverage for Qsymia.

 

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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 (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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