Does Regence Cover Phentermine/Topiramate ER (Qsymia)

Explore Regence coverage for Phentermine/Topiramate ER (Qsymia), costs without insurance, and get tips to maximize benefits in this comprehensive guide.
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Coverage Overview

 

  • Regence may cover Phentermine/Topiramate ER (Qsymia) under certain circumstances, mainly for chronic weight management in adults.

 

Eligibility Criteria

 

  • Patients usually need to have a BMI ≥ 30, or ≥ 27 with comorbid conditions like hypertension or diabetes.
  • A demonstrated failure of lifestyle modifications over time may be required.

 

Approval Process

 

  • Prior authorization is often necessary, which involves a detailed evaluation of the patient’s medical history.
  • Continued coverage might depend on achieving specific weight loss goals within a set period.

 

Important Considerations

 

  • Check your specific plan as benefits and coverage can vary.
  • Consult with healthcare providers to ensure proper documentation for submission.

 

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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 Regence

 

Verify Coverage Policies

 

  • Check Regence's official website for their specific coverage details on Phentermine/Topiramate ER (Qsymia). Each insurance provider may have unique policies and requirements for coverage.
  • Consult your Regence insurance policy document or contact their customer service to confirm if Qsymia is covered under your plan's pharmacy benefits.

 

Consult with Your Healthcare Provider

 

  • Discuss with your healthcare provider about your suitability for Phentermine/Topiramate ER (Qsymia) and obtain a prescription if deemed appropriate.
  • Ask your healthcare provider to provide any necessary documentation or medical justification for the prescription to expedite the insurance approval process.

 

Submit a Prior Authorization Request

 

  • Prior authorization is often required for medications like Phentermine/Topiramate ER (Qsymia). Have your healthcare provider submit a request to Regence on your behalf.
  • Complete any forms or paperwork required by Regence to initiate the prior authorization process, ensuring all medical details and justifications are thoroughly documented.

 

Follow Up on Authorization

 

  • Keep in touch with your healthcare provider and Regence to ensure that the prior authorization request is being processed.
  • Inquire about the typical time frame for authorization review and approval with Regence, and note any additional information needed to avoid delays.

 

Understand Your Co-payments and Coverage Limits

 

  • Once the medication is approved, review the co-pays, deductibles, or any out-of-pocket expenses associated with getting the prescription filled at your pharmacy.
  • Confirm any limits on coverage, such as quantity limits or lifetime caps, with your Regence policy to align expectations and avoid surprise costs.

 

Visit the Pharmacy

 

  • Go to a pharmacy that is within Regence's approved network to obtain the medication. Provide them with your prescription and insurance information.
  • Ensure that the pharmacist processes the prescription through your Regence plan to apply the coverage benefits correctly.

 

Appeal if Necessary

 

  • If your prior authorization request is denied, discuss with your healthcare provider about gathering additional information or medical documentation needed to support your appeal.
  • File an appeal with Regence following any denial, adhering to the procedures outlined in their correspondence or policy documents.

 

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FAQs

Does Regence Cover Phentermine/Topiramate ER (Qsymia)

Explore Regence coverage for Phentermine/Topiramate ER (Qsymia), costs without insurance, and get tips to maximize benefits in this comprehensive guide.
Curex allergy drops unboxing

Is Phentermine/Topiramate ER (Qsymia) Covered by Regence

 

Coverage Overview

 

  • Regence may cover Phentermine/Topiramate ER (Qsymia) under certain circumstances, mainly for chronic weight management in adults.

 

Eligibility Criteria

 

  • Patients usually need to have a BMI ≥ 30, or ≥ 27 with comorbid conditions like hypertension or diabetes.
  • A demonstrated failure of lifestyle modifications over time may be required.

 

Approval Process

 

  • Prior authorization is often necessary, which involves a detailed evaluation of the patient’s medical history.
  • Continued coverage might depend on achieving specific weight loss goals within a set period.

 

Important Considerations

 

  • Check your specific plan as benefits and coverage can vary.
  • Consult with healthcare providers to ensure proper documentation for submission.

 

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

 

Regence Coverage Criteria for Phentermine/Topiramate ER (Qsymia)

 

  • The patient must be an adult aged 18 or older.
  •  

  • The patient must have a body mass index (BMI) of 30 kg/m² or greater, indicating obesity. Alternatively, the patient could have a BMI of 27 kg/m² or greater if accompanied by at least one weight-related comorbidity.
  •  

  • Weight-related comorbidities may include conditions such as type 2 diabetes mellitus, hypertension, or dyslipidemia.
  •  

  • The patient must have previously attempted weight loss through lifestyle modification, including diet and exercise, but has been unsuccessful in achieving adequate weight reduction or maintenance.
  •  

  • The prescribing healthcare provider must determine that the patient has no contraindications for use, such as pregnancy, glaucoma, hyperthyroidism, or recent MAOI use.
  •  

  • The prescription must be initiated and monitored by a qualified healthcare professional with experience in managing obesity and related conditions.
  •  

  • The initial prescription may be approved for a limited duration, typically 3 months, to evaluate effectiveness and tolerance.
  •  

  • Continuation of therapy beyond the initial approval will require documented evidence of at least 3% weight loss from baseline.
  •  

  • Regular follow-up appointments with the prescribing healthcare professional must be scheduled to assess progress, manage potential side effects, and make necessary adjustments to the treatment plan.
  •  

  • Phentermine/Topiramate ER (Qsymia) should be part of a comprehensive weight management program, including continued lifestyle modification such as diet, exercise, and behavioral changes.

 

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

 

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

 

  • The request for coverage does not align with FDA-approved indications for Qsymia. FDA approval typically includes specified adult patients with a BMI of 30 or greater, or a BMI of 27 or greater with a weight-related condition such as hypertension, type 2 diabetes, or dyslipidemia.
  •  

  • The patient has not attempted lifestyle modifications such as a reduced-calorie diet or increased physical activity prior to the prescription request. Evidence of these prior attempts may be required as part of the coverage evaluation process.
  •  

  • There is insufficient medical documentation to demonstrate that all other prerequisite pharmacological therapies were attempted unsuccessfully before requesting Qsymia coverage. Regence often requires a comprehensive history of prior weight loss medications that did not produce desired outcomes.
  •  

  • The patient's medical history presents contraindications for Qsymia, such as pregnancy, hyperthyroidism, glaucoma, or known hypersensitivity to sympathomimetic amines, which would lead to automatic denial due to safety concerns.
  •  

  • Regence has determined that the prescribed dosage or use of Qsymia does not follow established guidelines or recommendations. Instances of off-label use or dosages higher than recommended without substantial justification are likely be denied.
  •  

  • A requested prescription refill does not comply with the provider’s step therapy protocols or exceeds the plan's authorized quantity limits. Step therapy often necessitates trying other drugs first before Qsymia can be covered.
  •  

  • There is an absence of necessary, detailed documentation from the prescribing healthcare provider, which might include failure to submit updated medical records or an inadequate explanation of the medical need for Qsymia.

 

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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 Regence

 

Verify Coverage Policies

 

  • Check Regence's official website for their specific coverage details on Phentermine/Topiramate ER (Qsymia). Each insurance provider may have unique policies and requirements for coverage.
  • Consult your Regence insurance policy document or contact their customer service to confirm if Qsymia is covered under your plan's pharmacy benefits.

 

Consult with Your Healthcare Provider

 

  • Discuss with your healthcare provider about your suitability for Phentermine/Topiramate ER (Qsymia) and obtain a prescription if deemed appropriate.
  • Ask your healthcare provider to provide any necessary documentation or medical justification for the prescription to expedite the insurance approval process.

 

Submit a Prior Authorization Request

 

  • Prior authorization is often required for medications like Phentermine/Topiramate ER (Qsymia). Have your healthcare provider submit a request to Regence on your behalf.
  • Complete any forms or paperwork required by Regence to initiate the prior authorization process, ensuring all medical details and justifications are thoroughly documented.

 

Follow Up on Authorization

 

  • Keep in touch with your healthcare provider and Regence to ensure that the prior authorization request is being processed.
  • Inquire about the typical time frame for authorization review and approval with Regence, and note any additional information needed to avoid delays.

 

Understand Your Co-payments and Coverage Limits

 

  • Once the medication is approved, review the co-pays, deductibles, or any out-of-pocket expenses associated with getting the prescription filled at your pharmacy.
  • Confirm any limits on coverage, such as quantity limits or lifetime caps, with your Regence policy to align expectations and avoid surprise costs.

 

Visit the Pharmacy

 

  • Go to a pharmacy that is within Regence's approved network to obtain the medication. Provide them with your prescription and insurance information.
  • Ensure that the pharmacist processes the prescription through your Regence plan to apply the coverage benefits correctly.

 

Appeal if Necessary

 

  • If your prior authorization request is denied, discuss with your healthcare provider about gathering additional information or medical documentation needed to support your appeal.
  • File an appeal with Regence following any denial, adhering to the procedures outlined in their correspondence or policy documents.

 

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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.

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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