Does Scripps Health Cover Phentermine/Topiramate ER (Qsymia)

Explore Scripps Health coverage for Qsymia, tackling potential denials, ways to secure approval, costs without insurance, and FAQs for informed decisions.
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Qsymia Coverage by Scripps Health

 

  • Scripps Health may cover Phentermine/Topiramate ER (Qsymia) for patients who meet specific medical criteria.
  •  

  • It is typically covered for patients with a Body Mass Index (BMI) of 30 kg/m² or higher, or 27 kg/m² with weight-related conditions such as hypertension, type 2 diabetes, or dyslipidemia.
  •  

  • Prior authorization might be required, ensuring the patient has tried other weight-loss methods without success.

 

Basic Rules and Criteria

 

  • Coverage often demands documentation of lifestyle modification attempts and previous weight loss treatments.
  •  

  • The healthcare provider may need to submit a detailed treatment plan outlining how Qsymia fits into the patient's overall weight management strategy.
  •  

  • Regular follow-ups to monitor progress and assess Qsymia's effectiveness are typically necessary.

 

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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.

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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.

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 Scripps Health

 

Verify Eligibility and Benefits

 

  • Contact Scripps Health member services by visiting their website or calling their customer service number to determine your eligibility for prescription medication coverage.
  • Inquire specifically about coverage for weight management medications, focusing on Phentermine/Topiramate ER (Qsymia).
  • Ask about any pre-authorization or specific criteria needed to qualify for coverage of these medications.

 

Consult with Your Healthcare Provider

 

  • Schedule an appointment with your primary healthcare provider to discuss your interest in starting Phentermine/Topiramate ER (Qsymia).
  • Ensure that your healthcare provider is aware of your medical history and weight management goals to assess the suitability of the medication for you.
  • Request that your healthcare provider submit any necessary documentation for pre-authorization or prior approval if required by Scripps Health.

 

Obtain a Prescription

 

  • Once your healthcare provider determines that Phentermine/Topiramate ER (Qsymia) is appropriate for you, obtain a written prescription.
  • Ensure the prescription is for the extended-release formulation, as there could be different specifications for various formulations.

 

Submit the Prescription

 

  • Submit your prescription to a pharmacy that is within the Scripps Health network, ensuring they have experience processing claims for Phentermine/Topiramate ER (Qsymia).
  • Ask the pharmacist to confirm the coverage details and identify any out-of-pocket expenses before filling the prescription.

 

Follow Up for Coverage Confirmation

 

  • After submission, follow up with both the pharmacy and Scripps Health to confirm that the prescription has been approved for coverage.
  • Check if any additional documentation or steps are needed, such as participation in a weight management program or follow-up visits with your healthcare provider for continued coverage.

 

Utilize Patient Assistance Programs

 

  • If you face challenges in obtaining coverage through Scripps Health, explore patient assistance programs offered by the manufacturer of Phentermine/Topiramate ER (Qsymia) for potential discounts or financial aid.
  • Contact the manufacturer's assistance program directly to inquire about qualification requirements and application procedures.

 

Stay Informed About Your Plan

 

  • Regularly review updates from Scripps Health regarding changes in medication coverage policies or changes in your specific health plan benefits.
  • Maintain communication with your healthcare provider and Scripps Health to ensure compliance with any ongoing requirements related to your treatment plan with Phentermine/Topiramate ER (Qsymia).

 

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FAQs

Does Scripps Health Cover Phentermine/Topiramate ER (Qsymia)

Explore Scripps Health coverage for Qsymia, tackling potential denials, ways to secure approval, costs without insurance, and FAQs for informed decisions.
Curex allergy drops unboxing

Is Phentermine/Topiramate ER (Qsymia) Covered by Scripps Health

 

Qsymia Coverage by Scripps Health

 

  • Scripps Health may cover Phentermine/Topiramate ER (Qsymia) for patients who meet specific medical criteria.
  •  

  • It is typically covered for patients with a Body Mass Index (BMI) of 30 kg/m² or higher, or 27 kg/m² with weight-related conditions such as hypertension, type 2 diabetes, or dyslipidemia.
  •  

  • Prior authorization might be required, ensuring the patient has tried other weight-loss methods without success.

 

Basic Rules and Criteria

 

  • Coverage often demands documentation of lifestyle modification attempts and previous weight loss treatments.
  •  

  • The healthcare provider may need to submit a detailed treatment plan outlining how Qsymia fits into the patient's overall weight management strategy.
  •  

  • Regular follow-ups to monitor progress and assess Qsymia's effectiveness are typically necessary.

 

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

 

Coverage Guidelines for Phentermine/Topiramate ER (Qsymia)

 

  • The patient must have a Body Mass Index (BMI) of 30 kg/m² or greater. For those with comorbid conditions such as hypertension, type 2 diabetes mellitus, or dyslipidemia, a BMI of 27 kg/m² or greater is required.
  •  

  • Documentation must show the patient has attempted lifestyle modifications including a reduced-calorie diet and increased physical activity, which did not result in significant weight loss.
  •  

  • Approval is subject to a comprehensive evaluation by the patient's healthcare provider, indicating that the potential benefits of treating with Phentermine/Topiramate ER outweigh potential risks.
  •  

 

Initiation Criteria

 

  • A documented discussion between the patient and healthcare provider about weight management options, risks, and benefits of pharmacotherapy, and agreement to start treatment with Qsymia.
  •  

  • The initial prescription is typically for a 3-month trial to evaluate the effectiveness and tolerance of the medication. Follow-up is required to assess progress before continuation.
  •  

 

Continued Coverage and Reassessment

 

  • Demonstrable weight loss of at least 3% from baseline within the initial 3 months of treatment. If this weight loss is not achieved, treatment reevaluation or cessation should be considered.
  •  

  • Ongoing treatment approval requires documented adherence to the medication and continued efforts in lifestyle modification efforts, consistent with a comprehensive weight management plan.
  •  

  • Regular follow-ups should be submitted, including weight measurements, assessment of comorbid conditions, and any side effects experienced by the patient.
  •  

Why Scripps Health Might Deny Phentermine/Topiramate ER (Qsymia) Coverage

 

Reasons for Denial of Phentermine/Topiramate ER (Qsymia) Coverage by Scripps Health

 

  • Phentermine/Topiramate ER (Qsymia) is not covered if it is deemed not medically necessary for the patient. This applies if the prescribed usage does not align with established medical guidelines or protocols.
  •  

  • Prescription requests for Phentermine/Topiramate ER (Qsymia) may be denied if the patient does not meet the specific Body Mass Index (BMI) criteria or other clinical criteria required for its approval.
  •  

  • If a patient has not demonstrated inadequate response, allergies, or contraindications to other less expensive weight loss medications, coverage might be denied.
  •  

  • The coverage might be denied if the patient has not completed the mandatory duration of diet and exercise regimen prior to requesting Phentermine/Topiramate ER (Qsymia).
  •  

  • Phentermine/Topiramate ER (Qsymia) will not be covered if the patient has a history of certain medical conditions, such as hyperthyroidism, glaucoma, or drug abuse, where the medication is contraindicated.
  •  

  • Requests for Phentermine/Topiramate ER (Qsymia) for off-label uses that are not approved by regulatory bodies will not be covered.
  •  

  • If the medication is requested in excess of the dosage guidelines typically recommended, it will not be covered.
  •  

  • Requests originating outside of the United States, where Scripps Health does not provide coverage, will be automatically denied.

 

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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 Scripps Health

 

Verify Eligibility and Benefits

 

  • Contact Scripps Health member services by visiting their website or calling their customer service number to determine your eligibility for prescription medication coverage.
  • Inquire specifically about coverage for weight management medications, focusing on Phentermine/Topiramate ER (Qsymia).
  • Ask about any pre-authorization or specific criteria needed to qualify for coverage of these medications.

 

Consult with Your Healthcare Provider

 

  • Schedule an appointment with your primary healthcare provider to discuss your interest in starting Phentermine/Topiramate ER (Qsymia).
  • Ensure that your healthcare provider is aware of your medical history and weight management goals to assess the suitability of the medication for you.
  • Request that your healthcare provider submit any necessary documentation for pre-authorization or prior approval if required by Scripps Health.

 

Obtain a Prescription

 

  • Once your healthcare provider determines that Phentermine/Topiramate ER (Qsymia) is appropriate for you, obtain a written prescription.
  • Ensure the prescription is for the extended-release formulation, as there could be different specifications for various formulations.

 

Submit the Prescription

 

  • Submit your prescription to a pharmacy that is within the Scripps Health network, ensuring they have experience processing claims for Phentermine/Topiramate ER (Qsymia).
  • Ask the pharmacist to confirm the coverage details and identify any out-of-pocket expenses before filling the prescription.

 

Follow Up for Coverage Confirmation

 

  • After submission, follow up with both the pharmacy and Scripps Health to confirm that the prescription has been approved for coverage.
  • Check if any additional documentation or steps are needed, such as participation in a weight management program or follow-up visits with your healthcare provider for continued coverage.

 

Utilize Patient Assistance Programs

 

  • If you face challenges in obtaining coverage through Scripps Health, explore patient assistance programs offered by the manufacturer of Phentermine/Topiramate ER (Qsymia) for potential discounts or financial aid.
  • Contact the manufacturer's assistance program directly to inquire about qualification requirements and application procedures.

 

Stay Informed About Your Plan

 

  • Regularly review updates from Scripps Health regarding changes in medication coverage policies or changes in your specific health plan benefits.
  • Maintain communication with your healthcare provider and Scripps Health to ensure compliance with any ongoing requirements related to your treatment plan with 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.

Each pharmacy in our network undergoes rigorous third-party testing through FDA and DEA certified labs. These tests focus on four key elements, ensuring both safety and efficacy for our treatments.

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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