Does Sharp Health Plan Cover Phentermine/Topiramate ER (Qsymia)

Explore Sharp Health Plan's coverage for Phentermine/Topiramate ER (Qsymia), denial reasons, cost without insurance, and FAQs.
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Coverage Criteria

 

  • Sharp Health Plan might cover Phentermine/Topiramate ER (Qsymia) for members diagnosed with obesity or overweight conditions, particularly when associated with other health issues such as hypertension or diabetes.

 

Basic Rules

 

  • Members usually require a prescription from a healthcare provider. The provider may need to demonstrate that alternative weight-loss medications or strategies have been ineffective.

 

Approval Process

 

  • The authorization process may involve submitting a prior authorization form that outlines the patient's medical history and treatment necessity.

 

Plan Details

 

  • It's essential to check specific plan details or contact Sharp Health Plan customer service, as coverage and criteria can vary by individual plans and policy updates.

 

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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.

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 Sharp Health Plan

 

Verify Eligibility and Coverage

 

  • Before starting the process, confirm that your Sharp Health Plan includes coverage for prescription medications like Phentermine/Topiramate ER (Qsymia). Review your policy details or contact the Sharp Health Plan customer service.
  •  

  • Check if you meet any prerequisites for coverage, such as medical necessity or prior authorization requirements.

 

Consult Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss the need for Phentermine/Topiramate ER (Qsymia) in your treatment plan.
  •  

  • Your healthcare provider may need to document your medical condition and the necessity for this medication and potentially provide supporting information for insurance purposes.

 

Complete Prior Authorization

 

  • Work with your healthcare provider to complete any required prior authorization forms, if necessary. This involves justifying the necessity of Qsymia to your insurance company to get the medication covered.
  •  

  • Submit the completed prior authorization request forms to Sharp Health Plan for review and approval.

 

Contact Sharp Health Plan

 

  • Reach out to Sharp Health Plan's customer service department to inquire about the current status of your prior authorization request and confirm whether additional documentation is needed.
  •  

  • Ensure you have all necessary information, including your member ID and any documentation provided by your healthcare provider, ready when speaking with Sharp Health Plan representatives.

 

Pharmacy Coordination

 

  • Once you receive approval for Phentermine/Topiramate ER (Qsymia), coordinate with your pharmacy to fill the prescription.
  •  

  • Inform the pharmacy about your insurance coverage approval to ensure proper billing under your Sharp Health Plan.

 

Appeal Denials

 

  • If your initial request is denied, review the denial letter for specific reasons and speak with your prescribing doctor about possible grounds for an appeal.
  •  

  • Prepare and submit an appeal with any additional support or documentation from your healthcare provider that might justify the necessity of the medication for your health.

 

Stay Informed and Proactive

 

  • Regularly check for any updates or changes to your insurance plan's drug formulary, as coverage options for medications can change.
  •  

  • Maintain open communication with your healthcare provider and your insurance plan to ensure ongoing access to required medications.

 

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FAQs

Does Sharp Health Plan Cover Phentermine/Topiramate ER (Qsymia)

Explore Sharp Health Plan's coverage for Phentermine/Topiramate ER (Qsymia), denial reasons, cost without insurance, and FAQs.
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Is Phentermine/Topiramate ER (Qsymia) Covered by Sharp Health Plan

 

Coverage Criteria

 

  • Sharp Health Plan might cover Phentermine/Topiramate ER (Qsymia) for members diagnosed with obesity or overweight conditions, particularly when associated with other health issues such as hypertension or diabetes.

 

Basic Rules

 

  • Members usually require a prescription from a healthcare provider. The provider may need to demonstrate that alternative weight-loss medications or strategies have been ineffective.

 

Approval Process

 

  • The authorization process may involve submitting a prior authorization form that outlines the patient's medical history and treatment necessity.

 

Plan Details

 

  • It's essential to check specific plan details or contact Sharp Health Plan customer service, as coverage and criteria can vary by individual plans and policy updates.

 

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

 

Eligibility Criteria for Coverage

 

  • Patients must have a documented BMI (Body Mass Index) of 30 kg/m² or greater. Alternatively, a BMI of 27 kg/m² or greater is acceptable if the patient has one or more weight-related comorbidities, such as hypertension, type 2 diabetes, or dyslipidemia.
  •  

  • Patient should have attempted weight loss through lifestyle modifications such as diet and exercise for at least 6 months, without achieving the desired results. Documentation of these attempts is required.
  •  

  • A healthcare provider must assess the patient to determine that the use of Phentermine/Topiramate ER (Qsymia) is medically necessary for weight management.

 

Prescribing Physician Requirements

 

  • The prescribing physician should be a licensed practitioner familiar with the treatment of obesity and related metabolic conditions.
  •  

  • The healthcare provider is required to submit a detailed evaluation of the patient’s health status and obesity-related medical history.

 

Prior Authorization and Documentation

 

  • Prior authorization is mandatory, and the prescribing physician must submit a comprehensive prior authorization request form.
  •  

  • The request should include lab results, a full medical history, and any previous attempts at medical or lifestyle interventions for weight management.
  •  

  • Documentation should verify that the patient does not have contraindications to the use of Phentermine/Topiramate ER (Qsymia).

 

Monitoring and Follow-Up

 

  • Regular monitoring of the patient's weight loss progress and any side effects is necessary. This should be documented at follow-up visits every 3 months.
  •  

  • If the patient doesn't exhibit a significant weight reduction (at least 3% of total body weight) within the first 12 weeks, the healthcare provider will reassess the treatment plan.

 

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

 

Non-medically Necessary Situations

 

  • If the prescribed usage of Phentermine/Topiramate ER (Qsymia) is for purposes other than the clinical indications approved by Sharp Health Plan, coverage may be denied.

 

Lack of Prior Authorization

 

  • Failure to obtain prior authorization when required by Sharp Health Plan for Phentermine/Topiramate ER (Qsymia) can result in denial of coverage.

 

Non-compliance with Specific Plan Requirements

 

  • Coverage may be denied if the patient does not meet the specific guidelines or requirements set by Sharp Health Plan for medication approval. This may include but is not limited to certain health conditions or demographic factors.

 

Off-label Use

 

  • Sharp Health Plan may not cover Phentermine/Topiramate ER (Qsymia) if it is being prescribed for off-label use not supported by clinical evidence or plan policies.

 

Quantity Limits Exceeded

 

  • Requests that exceed the established quantity limits set by Sharp Health Plan without valid justification or documentation may not be covered.

 

Excluded Health Conditions

 

  • Certain health conditions or situations that are explicitly excluded from coverage under Sharp Health Plan may lead to denial if associated with the use of Phentermine/Topiramate ER (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 Sharp Health Plan

 

Verify Eligibility and Coverage

 

  • Before starting the process, confirm that your Sharp Health Plan includes coverage for prescription medications like Phentermine/Topiramate ER (Qsymia). Review your policy details or contact the Sharp Health Plan customer service.
  •  

  • Check if you meet any prerequisites for coverage, such as medical necessity or prior authorization requirements.

 

Consult Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss the need for Phentermine/Topiramate ER (Qsymia) in your treatment plan.
  •  

  • Your healthcare provider may need to document your medical condition and the necessity for this medication and potentially provide supporting information for insurance purposes.

 

Complete Prior Authorization

 

  • Work with your healthcare provider to complete any required prior authorization forms, if necessary. This involves justifying the necessity of Qsymia to your insurance company to get the medication covered.
  •  

  • Submit the completed prior authorization request forms to Sharp Health Plan for review and approval.

 

Contact Sharp Health Plan

 

  • Reach out to Sharp Health Plan's customer service department to inquire about the current status of your prior authorization request and confirm whether additional documentation is needed.
  •  

  • Ensure you have all necessary information, including your member ID and any documentation provided by your healthcare provider, ready when speaking with Sharp Health Plan representatives.

 

Pharmacy Coordination

 

  • Once you receive approval for Phentermine/Topiramate ER (Qsymia), coordinate with your pharmacy to fill the prescription.
  •  

  • Inform the pharmacy about your insurance coverage approval to ensure proper billing under your Sharp Health Plan.

 

Appeal Denials

 

  • If your initial request is denied, review the denial letter for specific reasons and speak with your prescribing doctor about possible grounds for an appeal.
  •  

  • Prepare and submit an appeal with any additional support or documentation from your healthcare provider that might justify the necessity of the medication for your health.

 

Stay Informed and Proactive

 

  • Regularly check for any updates or changes to your insurance plan's drug formulary, as coverage options for medications can change.
  •  

  • Maintain open communication with your healthcare provider and your insurance plan to ensure ongoing access to required medications.

 

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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.

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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