Does UPMC Health Plan Cover Phentermine (Adipex-P, Lomaira)

Learn if UPMC Health Plan covers Phentermine. Explore denial reasons, coverage tips, cost without insurance, and answers to common questions.
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Coverage of Phentermine by UPMC Health Plan

 

  • UPMC Health Plan may cover Phentermine (Adipex-P, Lomaira) under specific conditions, focusing on medically necessary use for weight management.
  •  

  • Coverage often requires a documented diagnosis of obesity or overweight with related health conditions, alongside participation in a supervised weight loss program.
  •  

  • Prior authorization is typically required, involving a demonstration of previous unsuccessful attempts at weight loss through lifestyle changes.
  •  

  • Continuous monitoring and follow-up by the prescribing healthcare provider are essential to maintain coverage.
  •  

  • Criteria and coverage details are subject to change, so it is crucial to consult the specific policy documentation or contact UPMC Health Plan directly for the most accurate information.

 

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Curex is poised to revolutionize the way allergies are treated in America, expanding access to clinical care and treatments that can meaningfully improve patients quality of life.

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At Curex, our mission is to help people improve their health and quality of life by understanding their allergies and treating them at their source.We provide more than individualized prescription treatments; we provide individualized care.

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Immunotherapy made simple.  We enable patients to receive personalized allergy care on their own time. No more waiting rooms.

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 (Adipex-P, Lomaira) Coverage with UPMC Health Plan

 

Understand UPMC Health Plan Requirements

 

  • Research UPMC Health Plan’s coverage policies. Visit their website or contact their customer service to understand the specific requirements for covering weight management medications like Phentermine (Adipex-P, Lomaira).
  •  

  • Check if Phentermine is listed under their formulary. This is a list of medications that UPMC Health Plan covers, which may vary depending on your specific plan.

 

Consult Your Healthcare Provider

 

  • Discuss your weight management options with your healthcare provider. Ensure they are familiar with your health plan’s requirements for prescribing Phentermine.
  •  

  • Request a medical evaluation to determine if Phentermine is an appropriate option for you. Your provider should document this as it supports your need for the medication.

 

Pre-Authorization Process

 

  • Ask your healthcare provider to initiate a pre-authorization request for Phentermine. This step is crucial as it requires your doctor to provide medical justification for prescribing the medication.
  •  

  • Ensure all necessary documentation is submitted. This may include your BMI, weight management history, and any other relevant health conditions.

 

Contact UPMC Health Plan

 

  • Reach out to the UPMC Health Plan’s customer service for assistance with the pre-authorization process. They can provide you with specific forms or requirements needed for submission.
  •  

  • Inquire about the status of your pre-authorization request. You may need to follow up frequently to ensure all paperwork is processed correctly.

 

Review Coverage Decision

 

  • Wait for UPMC Health Plan’s decision regarding the coverage of Phentermine. This decision will outline whether the medication is approved or if additional steps are required.
  •  

  • If approved, review any co-payments, limitations, or conditions associated with the medication's coverage to fully understand your financial responsibilities.

 

Appeal if Necessary

 

  • If your request for coverage is denied, review the denial notice carefully to understand the reasons provided by UPMC Health Plan.
  •  

  • Work with your healthcare provider to gather additional documentation or evidence that supports your case and submit an appeal.

 

Refill and Manage Your Prescription

 

  • Once approved, follow your healthcare provider's guidance to fill your prescription at an approved pharmacy within the UPMC network.
  •  

  • Keep track of refill dates and any ongoing requirements for continued coverage to ensure uninterrupted access to Phentermine.

 

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Does UPMC Health Plan Cover Phentermine (Adipex-P, Lomaira)

Learn if UPMC Health Plan covers Phentermine. Explore denial reasons, coverage tips, cost without insurance, and answers to common questions.
Curex allergy drops unboxing

Is Phentermine (Adipex-P, Lomaira) Covered by UPMC Health Plan

 

Coverage of Phentermine by UPMC Health Plan

 

  • UPMC Health Plan may cover Phentermine (Adipex-P, Lomaira) under specific conditions, focusing on medically necessary use for weight management.
  •  

  • Coverage often requires a documented diagnosis of obesity or overweight with related health conditions, alongside participation in a supervised weight loss program.
  •  

  • Prior authorization is typically required, involving a demonstration of previous unsuccessful attempts at weight loss through lifestyle changes.
  •  

  • Continuous monitoring and follow-up by the prescribing healthcare provider are essential to maintain coverage.
  •  

  • Criteria and coverage details are subject to change, so it is crucial to consult the specific policy documentation or contact UPMC Health Plan directly for the most accurate information.

 

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UPMC Health Plan's Approved Criteria for Phentermine (Adipex-P, Lomaira) Coverage

 

Coverage Criteria for Phentermine (Adipex-P, Lomaira)

 

  • The member must be diagnosed with obesity, defined as a body mass index (BMI) of 30 kg/m² or higher, or with overweight, defined as a BMI of 27 kg/m² or higher, with at least one weight-related comorbidity, such as hypertension, type 2 diabetes, or hyperlipidemia.
  •  

  • Clinical documentation must indicate that the member has not achieved or maintained significant weight loss through a structured weight loss program, including lifestyle modifications like diet and exercise, for at least 6 months.
  •  

  • The member must be 16 years of age or older, aligning with the FDA-approved indications for the use of Phentermine.
  •  

  • Documentation of a comprehensive weight management plan must be submitted, which clearly shows the intention to use Phentermine as part of a multifaceted approach, including ongoing lifestyle changes and behavioral counseling.
  •  

  • The prescribing healthcare provider must confirm in the documentation that the member does not have contraindications to the use of Phentermine or any severe cardiac conditions that can be exacerbated by Phentermine use.
  •  

  • Phentermine therapy will be approved initially for a short-term course, per FDA label, with evaluation required for continued use based on the patient's weight loss progress and response to the medication, documented and submitted by the healthcare provider.
  •  

  • Coverage will consider potential drug interactions, especially with medications the member is currently using, and will require documentation from the prescribing provider to ensure the safety and feasibility of Phentermine use alongside other treatments.

 

Why UPMC Health Plan Might Deny Phentermine (Adipex-P, Lomaira) Coverage

 

Reasons UPMC Health Plan Might Deny Phentermine Coverage

 

  • Phentermine is not prescribed for the approved on-label uses. The medication might be denied if not aligned with its use for short-term weight management in the treatment of obesity.
  •  

  • The patient does not meet the necessary Body Mass Index (BMI) criteria. If the patient's BMI does not fall within the specified range required for coverage, typically a BMI of 30 or more, or 27 with related risk factors, coverage may be denied.
  •  

  • Absence of documented obesity-related risk factors. The Health Plan might require documentation showing associated comorbidities like hypertension or type 2 diabetes, and absence of such documentation could lead to denial.
  •  

  • Lack of prior authorization approval. UPMC Health Plan may require prior authorization for Phentermine, and lack of approval can result in denied claims.
  •  

  • Duration of usage exceeds recommended limits. Phentermine is generally approved for short-term usage, and prescriptions beyond the typical duration may not be covered.
  •  

  • Not adhering to a comprehensive weight management program. Coverage might require participation in a structured weight loss program, and failure to adhere to these requirements could result in denial.
  •  

  • Usage by patients with contraindications. If the patient has a history of cardiovascular disease, hyperthyroidism, or glaucoma, among other contraindications, Phentermine may not be covered.

 

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How Much Does Phentermine (Adipex-P, Lomaira) Cost without Insurance?

 

Cost of Phentermine (Adipex-P, Lomaira) Without Insurance

 

  • The price of Phentermine can vary based on the pharmacy location and dosage strength. Typically, the cost for Adipex-P (the tablet form) without insurance is approximately $30 to $100 for a 30-day supply, at the standard dose of 37.5 mg per tablet.
  •  

  • Lomaira, which is a lower-dosage version of Phentermine, might be priced differently. The average cost without insurance for Lomaira is around $50 to $90 for a 30-day supply, depending on the pharmacy and location.
  •  

  • It's worth noting that these costs reflect retail prices, and there might be cheaper generic options available. Additionally, some pharmacies offer discount programs or coupons which can significantly lower the price.
  •  

  • Shopping around at different pharmacies or using online resources may help in obtaining the best available price without insurance.

 

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 (Adipex-P, Lomaira) Coverage with UPMC Health Plan

 

Understand UPMC Health Plan Requirements

 

  • Research UPMC Health Plan’s coverage policies. Visit their website or contact their customer service to understand the specific requirements for covering weight management medications like Phentermine (Adipex-P, Lomaira).
  •  

  • Check if Phentermine is listed under their formulary. This is a list of medications that UPMC Health Plan covers, which may vary depending on your specific plan.

 

Consult Your Healthcare Provider

 

  • Discuss your weight management options with your healthcare provider. Ensure they are familiar with your health plan’s requirements for prescribing Phentermine.
  •  

  • Request a medical evaluation to determine if Phentermine is an appropriate option for you. Your provider should document this as it supports your need for the medication.

 

Pre-Authorization Process

 

  • Ask your healthcare provider to initiate a pre-authorization request for Phentermine. This step is crucial as it requires your doctor to provide medical justification for prescribing the medication.
  •  

  • Ensure all necessary documentation is submitted. This may include your BMI, weight management history, and any other relevant health conditions.

 

Contact UPMC Health Plan

 

  • Reach out to the UPMC Health Plan’s customer service for assistance with the pre-authorization process. They can provide you with specific forms or requirements needed for submission.
  •  

  • Inquire about the status of your pre-authorization request. You may need to follow up frequently to ensure all paperwork is processed correctly.

 

Review Coverage Decision

 

  • Wait for UPMC Health Plan’s decision regarding the coverage of Phentermine. This decision will outline whether the medication is approved or if additional steps are required.
  •  

  • If approved, review any co-payments, limitations, or conditions associated with the medication's coverage to fully understand your financial responsibilities.

 

Appeal if Necessary

 

  • If your request for coverage is denied, review the denial notice carefully to understand the reasons provided by UPMC Health Plan.
  •  

  • Work with your healthcare provider to gather additional documentation or evidence that supports your case and submit an appeal.

 

Refill and Manage Your Prescription

 

  • Once approved, follow your healthcare provider's guidance to fill your prescription at an approved pharmacy within the UPMC network.
  •  

  • Keep track of refill dates and any ongoing requirements for continued coverage to ensure uninterrupted access to Phentermine.

 

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Phentermine (Adipex-P, Lomaira) FAQ

What are the side effects of phentermine?

 

Common Side Effects

 

  • Increased heart rate
  • Insomnia
  • Anxiety
  • Dry mouth

 

Less Common Side Effects

 

  • Dizziness
  • Constipation
  • Chest discomfort

 

Severe Side Effects

 

  • Shortness of breath
  • Severe headache
  • Heart palpitations

 

Recommendations

 

  • Avoid combining with other stimulants.
  • Limit alcohol consumption.
  • Consult a physician if side effects are severe or persist.

 

Important Note

 

  • Use only as prescribed by your doctor.
  • Avoid taking it late in the day to prevent insomnia.

 

How does phentermine help with weight loss?

 

How Phentermine Aids Weight Loss

 

  • Phentermine suppresses appetite by releasing neurotransmitters like norepinephrine in the brain, which helps reduce hunger.
  •  

  • It is similar to an amphetamine and works by stimulating the central nervous system, increasing heart rate and blood pressure, which can decrease appetite.
  •  

  • The medication should be combined with a reduced-calorie diet, increased physical activity, and behavior therapy for optimal results.
  •  

  • Often used for short-term management of obesity, typically up to 12 weeks, as part of a broader weight-loss program.

 

Is phentermine safe to use long-term?

 

Phentermine Safety

 

  • Phentermine is mainly prescribed for short-term use, generally up to 12 weeks, due to the lack of long-term efficacy and safety studies.
  •  

  • While it can be effective for weight loss over a short period, the potential for dependency and cardiovascular issues makes prolonged use risky.
  •  

  • Long-term use may lead to side effects like elevated blood pressure, palpitations, insomnia, and mood changes.
  •  

  • Consult your healthcare provider regularly to evaluate its ongoing necessity and monitor any adverse effects.
  •  

  • Alternative weight management strategies, such as lifestyle changes, should be prioritized for sustainable results.

 

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Your initial medication and dosage are carefully determined by doctors, taking into account your unique health profile. This ensures a personalized and safe treatment plan tailored to your specific needs.

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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