Does SummaCare Cover Phentermine/Topiramate ER (Qsymia)

Explore why SummaCare may deny Qsymia coverage, how to get it, costs without insurance, and commonly asked questions in this comprehensive guide.
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Phentermine/Topiramate ER (Qsymia) Coverage by SummaCare

 

  • SummaCare may cover Phentermine/Topiramate ER (Qsymia) under specific conditions; however, coverage often depends on the individual's health plan and medical necessity.
  •  

  • Typically, coverage is considered for patients diagnosed with obesity (a BMI of 30 or greater) or overweight (a BMI of 27 or greater) with related comorbidities, such as hypertension, type 2 diabetes, or dyslipidemia.
  •  

  • Prior authorization is usually required, meaning the healthcare provider must submit a request that justifies the medical necessity of the drug.
  •  

  • In some cases, a trial of weight management program participation is needed to demonstrate the patient's commitment to lifestyle changes.
  •  

  • Insurance plans often require that less costly weight management medication options have been explored before approving Qsymia.

 

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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 SummaCare

 

Research SummaCare Coverage

 

  • Contact SummaCare to determine if Phentermine/Topiramate ER (Qsymia) is included in your specific plan's formulary.
  •  

  • Visit the SummaCare website and log into your member account to examine the list of covered medications.
  •  

  • Check for any policy updates or guidelines related to weight management prescriptions.

 

Consult with Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss the suitability of Phentermine/Topiramate ER (Qsymia) for your health needs.
  •  

  • Ensure your provider is aware of SummaCare's requirements and guidelines for prescribing weight management medications.
  •  

  • Ask your healthcare provider to document the medical necessity for this prescription in your medical records.

 

Obtain Prior Authorization

 

  • Request your healthcare provider to obtain prior authorization from SummaCare for Phentermine/Topiramate ER (Qsymia).
  •  

  • Provide any necessary documentation or supporting information required by SummaCare to process the prior authorization.
  •  

  • Follow up regularly with your healthcare provider to ensure the prior authorization is moving forward.

 

Prepare and Submit the Necessary Documentation

 

  • Collect all required documentation, including your healthcare provider's prescription, medical records, and any relevant health assessments.
  •  

  • Submit this documentation as per SummaCare's specified process, either through their website, via fax, or through the mail.
  •  

  • Confirm receipt of your documentation with SummaCare and address any additional information requests promptly.

 

Appeal if Necessary

 

  • If coverage is denied, contact SummaCare to understand the denial reason and the steps for filing an appeal.
  •  

  • Work with your healthcare provider to provide additional information or clarification needed for the appeal process.
  •  

  • Submit the appeal within the required timeline and be proactive in following up with SummaCare regarding the appeal's status.

 

Stay Informed

 

  • Regularly check your SummaCare benefits to stay updated on any changes to prescription drug coverage.
  •  

  • Participate in wellness programs or initiatives offered by SummaCare that may support your health goals and potential medication needs.
  •  

  • Keep an open line of communication with both SummaCare and your healthcare provider to promptly address any future prescription needs.

 

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FAQs

Does SummaCare Cover Phentermine/Topiramate ER (Qsymia)

Explore why SummaCare may deny Qsymia coverage, how to get it, costs without insurance, and commonly asked questions in this comprehensive guide.
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Is Phentermine/Topiramate ER (Qsymia) Covered by SummaCare

 

Phentermine/Topiramate ER (Qsymia) Coverage by SummaCare

 

  • SummaCare may cover Phentermine/Topiramate ER (Qsymia) under specific conditions; however, coverage often depends on the individual's health plan and medical necessity.
  •  

  • Typically, coverage is considered for patients diagnosed with obesity (a BMI of 30 or greater) or overweight (a BMI of 27 or greater) with related comorbidities, such as hypertension, type 2 diabetes, or dyslipidemia.
  •  

  • Prior authorization is usually required, meaning the healthcare provider must submit a request that justifies the medical necessity of the drug.
  •  

  • In some cases, a trial of weight management program participation is needed to demonstrate the patient's commitment to lifestyle changes.
  •  

  • Insurance plans often require that less costly weight management medication options have been explored before approving Qsymia.

 

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

 

SummaCare Coverage Criteria for Phentermine/Topiramate ER (Qsymia)

 

  • Phentermine/Topiramate ER (Qsymia) is covered for patients diagnosed with a Body Mass Index (BMI) of 30 kg/m² or greater.
  •  

  • Coverage is available for patients with a BMI of 27 kg/m² or greater who also have weight-related comorbidity conditions such as hypertension, type 2 diabetes mellitus, or dyslipidemia.
  •  

  • Patients must demonstrate prior weight management efforts through lifestyle modifications, including dietary changes, exercise, and behavior therapy, which did not result in significant weight loss.
  •  

  • Prescribing of Phentermine/Topiramate ER (Qsymia) must be initiated and overseen by a healthcare provider experienced in managing obesity and its related conditions.
  •  

  • Patients undergoing treatment consent to regular monitoring of weight loss progress and potential side effects by their healthcare provider, with follow-up visits scheduled to assess the efficacy and safety of the medication.
  •  

  • Continuation of coverage for Phentermine/Topiramate ER (Qsymia) is contingent upon achieving a 3% weight reduction from baseline in the first 12 weeks; if this threshold is not met, the healthcare provider needs to assess the treatment plan.
  •  

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

 

Situations Where SummaCare Might Deny Coverage for Phentermine/Topiramate ER (Qsymia)

 

  • **Non-Medically Necessary**: If the medication is deemed not medically necessary according to SummaCare's guidelines, they may deny coverage.
  •  

  • **Lack of Prior Authorization**: If prior authorization is required and has not been obtained or approved, SummaCare might deny coverage for Qsymia.
  •  

  • **Off-Label Use**: Coverage may be denied if the medication is prescribed for off-label uses that are not approved by SummaCare.
  •  

  • **Exceeding Quantity Limits**: SummaCare may have set quantity limits on Qsymia. If a prescription exceeds these limits, coverage might be denied.
  •  

  • **Eligibility Criteria Not Met**: If a member does not meet the specific eligibility criteria outlined by SummaCare for obesity treatment, coverage may be denied.
  •  

  • **Previous Authorization Expired**: Coverage can be denied if the previous authorization has expired and a new one has not been obtained for continued use.
  •  

  • **Non-Compliance with Treatment Guidelines**: Failure to adhere to the recommended treatment guidelines or monitoring requirements set by SummaCare could result in denial of coverage.
  •  

  • **Conflict with Other Medications**: If there is a potential conflict or contraindication with other medications that the member is taking, coverage could be denied.
  •  

  • **Failure to Attempt Alternative Therapies**: If alternative weight loss therapies have not been tried and documented, SummaCare might deny coverage 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 SummaCare

 

Research SummaCare Coverage

 

  • Contact SummaCare to determine if Phentermine/Topiramate ER (Qsymia) is included in your specific plan's formulary.
  •  

  • Visit the SummaCare website and log into your member account to examine the list of covered medications.
  •  

  • Check for any policy updates or guidelines related to weight management prescriptions.

 

Consult with Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss the suitability of Phentermine/Topiramate ER (Qsymia) for your health needs.
  •  

  • Ensure your provider is aware of SummaCare's requirements and guidelines for prescribing weight management medications.
  •  

  • Ask your healthcare provider to document the medical necessity for this prescription in your medical records.

 

Obtain Prior Authorization

 

  • Request your healthcare provider to obtain prior authorization from SummaCare for Phentermine/Topiramate ER (Qsymia).
  •  

  • Provide any necessary documentation or supporting information required by SummaCare to process the prior authorization.
  •  

  • Follow up regularly with your healthcare provider to ensure the prior authorization is moving forward.

 

Prepare and Submit the Necessary Documentation

 

  • Collect all required documentation, including your healthcare provider's prescription, medical records, and any relevant health assessments.
  •  

  • Submit this documentation as per SummaCare's specified process, either through their website, via fax, or through the mail.
  •  

  • Confirm receipt of your documentation with SummaCare and address any additional information requests promptly.

 

Appeal if Necessary

 

  • If coverage is denied, contact SummaCare to understand the denial reason and the steps for filing an appeal.
  •  

  • Work with your healthcare provider to provide additional information or clarification needed for the appeal process.
  •  

  • Submit the appeal within the required timeline and be proactive in following up with SummaCare regarding the appeal's status.

 

Stay Informed

 

  • Regularly check your SummaCare benefits to stay updated on any changes to prescription drug coverage.
  •  

  • Participate in wellness programs or initiatives offered by SummaCare that may support your health goals and potential medication needs.
  •  

  • Keep an open line of communication with both SummaCare and your healthcare provider to promptly address any future prescription needs.

 

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Phentermine/Topiramate ER (Qsymia) FAQ

What are the common side effects of Phentermine/Topiramate ER (Qsymia)?

 

Common Side Effects of Qsymia

 

  • **Paraesthesia:** Often described as a tingling sensation, typically in the hands and feet.
  •  

  • **Dizziness and lightheadedness:** These sensations may occur, especially when standing up quickly.
  •  

  • **Dry mouth:** Increased thirst or the feeling of not having enough saliva can be common with Qsymia use.
  •  

  • **Insomnia:** Difficulty falling asleep or staying asleep may be experienced.
  •  

  • **Constipation:** A common digestive side effect, characterized by infrequent bowel movements.
  •  

  • **Taste alteration:** Some users report a change in taste perception or a metallic taste.

How effective is Qsymia for weight loss?

 

Effectiveness of Qsymia

 

  • Qsymia combines phentermine and topiramate ER, proven effective for weight loss by enhancing satiety and reducing appetite.
  •  

  • Clinical trials report an average weight loss of about 5%–10% of initial body weight over a year, higher than diet and exercise alone.
  •  

  • Study results can vary based on individual factors such as diet adherence and lifestyle changes.
  •  

 

Considerations

 

  • Best results occur alongside a reduced-calorie diet and increased physical activity.
  •  

  • Assess for potential side effects, including increased heart rate, mood changes, and birth defects if used during pregnancy.
  •  

  • Long-term efficacy beyond one year is less established, requiring ongoing lifestyle modifications for sustained weight management.

 

Can Qsymia be taken long-term for weight management?

 

Long-term Use of Qsymia

 

  • Qsymia is an obesity medication combining phentermine and topiramate. It's approved for long-term use along with a reduced-calorie diet and increased physical activity.
  •  

  • Potential benefits include sustainable weight loss, improved metabolic health, and reduced risk of obesity-related conditions.

 

Monitoring and Safety

 

  • Regular follow-ups with a healthcare provider are essential to monitor side effects and effectiveness.
  •  

  • Common side effects include numbness, dizziness, taste changes, and insomnia. More severe risks include mood alterations and birth defects.

 

Continuing Treatment

 

  • Periodic assessment is crucial to decide if continued treatment is appropriate based on weight loss progress and side effect profile.
  •  

  • Should significant weight loss not occur within 12 weeks, alternative therapies might be considered.

 

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Our clinicians may order labs and additional medications for you, which would not be covered by the plan but for which you can use your insurance.

Please note: Compounded medications are tailored to individual needs or used in case of shortages, but they are not FDA-approved for safety or effectiveness. A prescription is required. Results may vary from person to person.

What medications do your providers prescribe?

We prioritize a personalized approach to your health. If your medical provider prescribes medication, options may include GLP-1 treatments such as compounded semaglutide (the active ingredient in Wegovy®* and Ozempic®*). Our providers prescribe only combination treatments not available at your local pharmacy that may include vitamin B12, etc. to help you achieve your goals faster.

Depending on your treatment goals, other medications such as metformin may also be considered. We recognize the importance of managing side effects, so your care plan might include medication to ease symptoms like nausea. Your well-being is always our top priority!

Please note that compounded medications are customized to meet individual patient needs and are not FDA-approved for safety or effectiveness. A prescription is necessary. Results may vary from person to person.

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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