Does Blue Cross Blue Shield cover Qsymia?

In this article:

• Does Blue Cross Blue Shield cover Qsymia?
• How much does Qsymia cost?
• How much does Qsymia cost with BCBS?
• How to check whether your BCBS plan covers Qsymia
• What to do if insurance won’t cover Qsymia
• How to get Qsymia without insurance

In this article

• Does Blue Cross Blue Shield cover Qsymia?
• How much does Qsymia cost?
• How much does Qsymia cost with BCBS?
• How to check whether your BCBS plan covers Qsymia
• What to do if insurance won’t cover Qsymia
• How to get Qsymia without insurance

Qsymia is a brand-name prescription drug that contains the active ingredients phentermine and topiramate. The Food and Drug Administration (FDA) has approved it for weight loss and long-term weight management in adults and pediatric patients 12 years and older with obesity, as well as adults who are overweight with at least one weight-related health condition, such as high blood pressure or high cholesterol. Like all weight-loss drugs, Qsymia is recommended for use alongside lifestyle changes like a reduced-calorie diet and increased physical activity. If your healthcare provider has prescribed Qsymia, you will want to know if your Blue Cross Blue Shield (BCBS) plan pays for this medicine. The short answer is: Maybe. There are a lot of moving pieces, so you’ll want to check with your plan for more information about coverage and out-of-pocket costs. 

Does Blue Cross Blue Shield cover Qsymia?

It’s hard to say whether BCBS will cover Qsymia (brand or generic) in general. There are a lot of considerations. 

For example, since Qsymia generics have been approved by the FDA, some formularies (lists of covered drugs and their tiers) may cover generic versions instead of brand-name Qsymia. And even if the formulary lists brand-name Qsymia as a covered drug, that could change. Drug formularies aren’t updated in real time, so the information you find online may not be up to date. 

For instance, the BCBS Federal Employee Program currently lists both brand-name and generic Qsymia as covered drugs, but this may not reflect the most recent updates if the formulary has since changed.

BCBS not only has commercial health insurance plans (such as through an employer), but also Medicare prescription plans and Medicaid plans. Medicare prescription plans currently do not cover drugs used strictly for weight loss, which means Qsymia is not usually covered. Medicaid coverage varies by state, but the majority of insurance plans under Medicaid typically do not cover Qsymia. Medicaid and Medicare are expected to begin allowing some plans to cover GLP-1 drugs such as Wegovy or Zepbound for weight management (injectable drugs that are given as weekly doses), but this does not affect Qsymia coverage.

However, some weight loss drugs are FDA approved for other conditions, too. For example, Zepbound (tirzepatide) is FDA approved for long-term weight management, but it’s also approved for moderate to severe obstructive sleep apnea in adults with obesity. In cases like this, someone who cannot get coverage for a weight loss medication may be able to get coverage under another use, if their medical provider prescribes it for another FDA-approved indication. This does not apply to Qsymia, however, which is FDA approved only for weight loss.

RELATED: BCBS Wegovy prior authorization criteria

How much does Qsymia cost?

Without insurance or discounts, you can expect to pay about $282 for 30, 7.5 mg/46 mg capsules of brand-name Qsymia. 

Using your free SingleCare discount card, you can pay as low as $218 for brand-name Qsymia. And if you fill your prescription with generic phentermine-topiramate, you can pay as little as $63 for a one-month supply, compared to $225 without a discount.

The SingleCare card and coupons are accepted at more than 35,000 pharmacies in the U.S. and Puerto Rico. You can use the discount for your initial Qsymia prescription and for refills. 

How much does Qsymia cost with BCBS?

It’s hard to generalize an average patient responsibility because costs depend on your specific health plan. If you have a BCBS Medicare or Medicaid prescription plan, it is unlikely that Qsymia will be covered. If you have a commercial BCBS insurance plan, and either brand-name or generic Qsymia is included on your formulary, you can get an accurate estimate of your costs directly from your plan. 

How to check whether your BCBS plan covers Qsymia 

Since plans vary in their coverage, the most reliable way to find out whether your plan covers Qsymia is to check the formulary for the exact plan of your health insurance company. You can do this by:

• Logging in to the BCBS website to find drug coverage information for your specific plan
• Calling BCBS member services: The phone number should be on your ID card. Ask the representative your questions about Qsymia coverage and costs on your plan. 
• Asking your healthcare provider to send the prescription to your local pharmacy: The pharmacy staff can process the prescription through your plan and tell you right away if the drug is covered, not covered, or requires prior authorization before the insurance plan makes a final decision on coverage based on medical necessity. 

What to do if insurance won’t cover Qsymia

If your insurance plan does not initially cover Qsymia, ask your healthcare provider if they can submit a prior authorization (PA). Sometimes, plans require additional clinical information before making a coverage decision. If the PA is not approved, you can ask your provider to submit an appeal. If the appeal is denied, you can look into ways to save on paying for Qsymia without insurance or discuss other medications with your healthcare provider. 

How to get Qsymia without insurance

A great way to save money on your Qsymia prescription is by using a SingleCare coupon. You can use SingleCare at a participating pharmacy every month to save money on your prescription. Without insurance, you can expect to pay about $282 for a one-month supply of brand-name Qsymia. If you use a SingleCare discount card or coupon, you can pay as low as $218 for brand-name Qsymia or as low as $63 for the generic version, depending on your choice of pharmacy and location. 

Weight loss coupons and resources

Here are some other ways to save on Qsymia:

• Visit the Vivus Inc. manufacturer website to learn more about saving money on brand-name Qsymia. There are various options, depending on the type of insurance you have, and there are also savings options for those without insurance. Check the website to find out more about all of these options and eligibility criteria. 
• Reach out to different local pharmacies and ask if they stock generic Qsymia. If they do, you can ask about the price of this medicine, as well as the price difference for a one-month or three-month supply. Some pharmacies charge less when you purchase a larger quantity.
• Ask your pharmacist or healthcare provider if they know of any resources in your community that can help you pay for your medicine, such as health departments or clinics that offer free or lower-cost medicines.

If your price for Qsymia, or generic Qsymia, is still high, talk to your healthcare provider. There are many other alternatives to Qsymia that are effective for a weight loss treatment plan suited to your specific needs, and that may be covered by your insurance.