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GoodRx and Adipex/Phentermine Savings

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GoodRx home page

GoodRx has an app which can help save you money when you get your Adipex (generic: phentermine) script filled. Note that GoodRx does not typically help with savings on Qsymia, Contrave, or Saxenda as each company has its own savings program.

To use GoodRx to find the nearest pharmacy to you with the best price on Adipex (generic: phentermine):

  • Install the GoodRx app on your phone
  • Type “phentermine” in the search box
  • Don’t change anything on the “Configure Prescription” page
  • Click on “Search Prices
  • Change the location if you need to
  • Find the lowest price you want and select that pharmacy
  • Take a screenshot or write down the pharmacy name, street address, and zip code and when our staff asks for your pharmacy, provide this info to them (or preferrably enter it into your Athena portal prior to your appointment)

 

Insurance Exclusions and Weight Loss Surgery

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Insurance

Many times patients who do not have coverage for weight loss surgery will ask us to file an appeal.  Will this work?  The short answer is no.  Read on for the long answer…

If your insurance does not cover weight loss surgery, this is called an “exclusion.”  This means that the employer who provides the insurance chose to exclude surgical weight loss from coverage in order to purchase a cheaper plan.  Once you understand this fact, it’s easier to understand why you can’t file an appeal and get them to cover it, no matter how severe your obesity might be.

If insurance companies were to allow this, then no employer would ever opt for the more expensive plans that do cover bariatric surgery. They would just buy the bare bones coverage and then tell their employees to all file appeals to get it covered anyway.

Unfortunately, when patients call their carriers, someone on the other end of the line (who actually works for the insurance company) will tell  you that you can file an appeal.  This is technically true, as you can file an appeal for anything your insurance denies.  However, in this case the appeal will never work because the issue is not one of medical necessity; in otherwords the insurance company is not saying that you don’t need the operation, they are denying it because you do not have the right type of coverage.  It would be somewhat like having a tree fall on your house and asking your car insurance to pay for it.  Or, perhaps more appropriately, asking your homeowners to pay for flood damage when it is specifically excluded from your homeowners policy.  It simply isn’t going to happen.

Also unfortunate (at least in Ohio, Kentucky and Indiana) is that marketplace policies purchased by individuals under the Affordable Care Act also exclude weight loss surgery.  Medicare, Medicaid, and most managed-care Medicaid plans such as CareSource, do cover weight loss surgery, however.

We wish that all Americans had access to life-saving surgical weight loss procedures, and maybe some day that will happen.  In the meantime, patients with exclusions essentially have two options:

Do I have coverage for Saxenda?

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Display Saxenda pen injectorSaxenda can be a very effective weight loss tool, however it is important to know your coverage and out-of-pocket expenses in order for us to determine whether it is a viable option for you.

Fortunately Vivus, the manufacturer or Saxenda, provides a help line to assist patients with figuring this out.

Before you call the help line make sure you have:

The coverage help line number is 1-888-809-3942.  Please ask the case manager the following questions:

  • Do I have coverage? (Yes/No)
  • If yes, what is my out-of-pocket cost?
  • Is a prior authorization required? (Yes/No)

Make sure you write this all down and bring it to your appointment, as we cannot prescribe Saxenda until we can review this information!

Weight Loss Surgery In Low BMI Patients

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Unfortunately in the field of weight loss surgery we use the phrase “NIH criteria” frequently.  What does this mean?  If refers to a 1991 National Institute of Health consensus statement on which patients should qualify for weight loss surgery.  That’s right folks, we are basing our decisions today on a loose set of mandates from 22+ years ago, when all procedures were open, were mostly gastric bypass, and had a mortality rate of 1-2%.

Nowadays the gastric sleeve is the most commonly performed procedure, and nearly all procedures are done with a laparoscopic, minimally invasive technique.  Therefore both the short-term and long-term risk of bariatric surgery is a least an order of magnitude lower than in 1991.  Yet most insurance companies still follow these outdated guidelines.

The truth is that class I or II obesity is associated with increased risk for weight related medical issues and mortality.

Weight loss and metabolic surgery in patients who continue to struggle with class 1 or II obesity, in the setting of failed attempts at lifestyle modification & weight loss programs is proven effective at leading to significant weight loss and an overall reduction in comordities and cardiovascular risk.

Also, it has been shown that diet, exercise and pharmacotherapy are largely ineffective for achieving significant or durable weight loss. In this setting, weight loss surgery is reasonable and is supported by the recent American Society of Metabolic and Bariatric Surgery’s position statement in 2018 (Surgery for Obesity and Related Diseases 14 (2018) 1071-1087).

Obesity is probably the only disease where we make patients wait until they are sicker and a higher operative risk to offer them the most treatment option, which is weight loss surgery. We need a change in thinking here as lower BMI patients often times have a higher success rate and are almost always a lower operative risk. Waiting until a patient is heavier and sicker is not the best strategy!

Immunospressants/Steroids After Weight Loss Surgery

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Immunosuppressants/Steroids Before & After Surgical Weight Loss

NOTE:  These are general guidelines, your surgeon may elect to use a different protocol so please discuss this with your specific provider.  It is very important to have a plan in place when it comes to these medications, otherwise it could result in your surgery being canceled or delayed!

Steroids (prednisone, methylprednisolone, Medrol Dose-Pak, etc):  

Sleeve/SIPS/Band:  

  • Ideally a patient will wean off chronic oral steroids (prednisone) completely by 4 weeks prior to surgery, and hold it for 4 weeks after surgery.  
      • Short-term steroids such as a Medrol dose pack or intra-muscular injections need to be held for 4 weeks prior and 4 weeks after also.  
      • Injectable steroids in joints or epidural space need to be held for 2 weeks prior and 2 weeks after.  
      • Topical and/or inhaled steroids are ok and do not need to be stopped.

Bypass:  

      • Gastric bypass patients cannot take steroids ever, therefore if a patient takes chronic steroids they are not a candidate for the procedure at all.    
      • Short-term steroids such as a Medrol dose pack or intra-muscular injections need to be held for 4 weeks prior and 4 weeks after also.    
      • Injectable steroids in joints or epidural space need to be held for 2 weeks prior and 2 weeks after. 
      • Topical and/or inhaled steroids are ok and do not need to be stopped.

Methotrexate:  Ideally a patient will stop methotrexate 4 weeks prior to any weight loss surgery, and resume it 4 weeks after surgery.  If the patient cannot tolerate a drug-free interval it is ok in certain cases to continue through and after surgery, as there is some literature to suggest it is safe.

Plaquenil:  Ideally a patient will stop plaquenil 4 weeks prior to any weight loss surgery, and resume it 4 weeks after surgery.  If the patient cannot tolerate a drug-free interval it is ok in certain cases to continue through and after surgery, as there is some literature to suggest it is safe.

TNF Inhibitors (Remicade, Humira, Enbrel, etc):  These medications should be held for 1 dosing cycle.  This translates to:

  • Remicade: 6-8 weeks depending on dose
  • Humira: 2 weeks
  • Enbrel: 1 week
  • TNF Inhibitors can be resumed 2 weeks after surgery.

If you take any of these medications and are unsure what you should do prior to surgery, please contact us at provider@curryweightloss.com!

How do you start Adipex (phentermine)?

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adipexJourneyLite Physicians has extensive experience with medical weight loss and appetite suppressants.  If one of our providers prescribed phentermine for you, it’s important to know how to start your medication and what to watch out for.

First of all, Adipex and phentermine are the exact same drug, Adipex is merely a brand name.  Usually our practice will write scripts for phentermine, as it is cheaper and has the same efficacy.  The bottle will usually say “Take 1 tablet daily” however there are some things to be aware of when starting out on phentermine!

  • Get your prescription filled ASAP, as after 72 hours many pharmacies will not fill phentermine scripts.
  • For the first week we recommend taking only a half tablet a day.  This helps your body get used to the medication and minimizes the risk of side effect.
    • After a week on a half tablet a day, if you haven’t had any side effects then go up to a full tablet daily.
  • Since phentermine is a stimulant we recommend monitoring your blood pressure for the first couple of weeks.
    • If the top number is over 140, or the bottom number is over 85 please contact the office!
    • If you don’t have a blood pressure cuff just go to your nearest pharmacy and use their machine.
  • It’s best to take your phentermine around 12 hours prior to bed time.
    • If you’re having trouble sleeping, take it a little earlier.
    • If you’re struggling with hunger in the evenings and not having any sleep issues, take it a little later.

The most common side effect by far is dry mouth.  This can be remedied by drinking lots of fluids, or utilizing OTC dry mouth losenges (such as Biotene).  Headaches can also occur when starting the medication, but as long as blood pressure isn’t elevated these will typically fade over a few days.  If you experience rare side effects such as chest pain or a rapid heart rate, please stop the medication and call the office immediately, even if after hours.

Weight loss 1 month after surgery predicts long-term success!

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Recently I attended a lecture by Dr. Dana Portenier, a respected bariatric surgeon from Duke University.  He spoke about a study published by their practice showing that a patients success after weight loss surgery can be predicted as early as at the 1 month post-op visit.

In the graphs below, you can see that for a patient with a BMI under 50, if they have lost 6% of their excess body weight at the 1 month visit, they will be in the bottom 5th percentile at 36 months.  A patient who has lost 26% of excess body weight, on the other hand,  will be in the 95th percentile!

Weight Loss At First Post-operative Visit Predicts Long-Term Outcome Of Roux-en-Y Gastric Bypass Using Duke Weight Loss Surgery Chart

Surgery for Obesity and Related Diseases 8 (2012) 556-550

EWL-followup graph for BMI under 50
EWL-followup graph for BMI over 50

This is something that I’ve always suspected but have never seen presented in such an elegant fashion.  You might ask, what is percent excess body weight loss?  In order to know this, you must first know what your excess body weight is.  This is simple: your excess body weight is your current weight minus your ideal body weight.  You can look up your ideal body weight multiple ways, such as here.

So let’s say you weigh 250 lbs and your ideal body weight is 150 lbs. This makes it easy, as your excess body weight is 100 lbs! If you lose 50 lbs then you have lost half (or 50%) of your excess body weight. Surgeons will often abbreviate as 50% EWL or 50% EBWL.

Here is an excellent article that will help you figure out what your excess body weight loss is, and you can refer to the graph above to see where you fall on the curve.

One of our goals at JourneyLite Physicians is to provide the best outcomes for our patients, and given this data we want patients to adhere to the follow-up schedule of:

  • monthly visits for the first year after surgery
  • visits every 3 months during the second year
  • visits every 6 months starting in the third year and beyond

We feel that more closely-spaced appointments will help patients stay on track better and give them every opportunity to succeed!

Click here to request a follow-up appointment.

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Supervised Diet Tips

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Insurance Tips

Supervised Diet Manual

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Supervised Diet Tips

Supervised diets are frequently required by insurance companies prior to authorization for weight loss surgeries such as gastric sleeve or gastric bypass.  There is no data published that shows supervised diets improve any outcomes whatsoever. However it is still very common for patients to have to go through a 3-month or 6-month program and demonstrate an overall weight loss from start to finish.  Here are some tips to ensure a smooth approval process for your weight loss procedure!

  • How many visits are required?
    • The vast majority of plans require either 3 months or 6 months.  Some require none at all.  Rarely, plans will require more than 6 months. Work with your insurance team or call your carrier to find out exactly how many is required for your specific plan.
  • Will they count your initial consult?
    • Some carriers will allow you to count your initial consultation as your first supervised diet visit. Others exclude it and don’t start counting until the next visit. Find out what your policy requires so you can plan properly.
  • Are any specific weight loss goals are required?
    • Some plans just require that you complete the specific number of supervised diet visits.  Others require an overall weight loss from start to finish. It is uncommon, but not unheard of, for there to be a specific weight loss requirement. You need to know for sure so that if a goal is required, you can make sure you it.
  • With whom can you do your supervised diet?
    • Sometimes you have to do your supervised diet with your surgeons office.  Other times it’s required to do it with someone other than your surgeon. Don’t waste your time by doing your supervised diet with the wrong doctor!  If you are going to do your supervised diet with your PCP, here is a helpful form to take to each visit to make sure documentation is complete.
  • What is your BMI minimum?
    • All policies will have a certain BMI which you must be above in order to qualify for surgery.  Most of the time this is:
      • A BMI of 35-40 with at least two weight-related issues (diabetes, sleep apnea, etc) OR
      • A BMI above 40, regardless of weight-related issues
    • Find out what your policy requires and whether you have qualifying weight-related issues, and find out what your weight would be at that minimum BMI to make sure you don’t drop below that.  If you do, it would most likely disqualify you from approval.  You can use a reverse BMI calculator to help you figure this out.
  • Are there any other requirements?
  • Make sure you have a visit each month, but not more than once per month.
    • Make sure you come in for a supervised diet visit around every 4 weeks, but not twice in one month.  For example, let’s say you came in for supervised diet visits on January 1st, January 31st, and March 1st. Your carrier would most likely say you skipped February, even though you were coming in around every 4 weeks.  A visit January 1st, February 1st, and March 1st would solve this problem, even though there is only a 1-day difference in the middle visit!
  • Make sure your last one is really your last one!
    • After your complete what you think is your final supervised diet visit, make 100% sure that it really is the last one needed.  If there is any uncertainty whatsoever, do another one the following month.  If for any reason it is determined that you needed one more, and more than a month has passed since your last one, you have to start over at the beginning!

Navigating a supervised diet requirement is not difficult once you get all the facts, so make sure you have gathered all the proper requirements for your plan. If you have any questions or unsure about any of your requirements, please email our insurance team at insurance@curryweightloss.com.

Band-To-Sleeve Conversion with Medtronic’s New Signia Smart Stapler

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Band-To-Sleeve Conversion

Band-to-sleeve conversion is becoming a more popular procedure amongst weight loss surgeons.  The gastric band, once the most popular weight loss surgery in the world, has worked well for many patients over the years. However, some patients either had issues requiring removal of their band, or perhaps didn’t achieve their weight loss goals due to the limited power of gastric banding in higher BMI patients. At JourneyLite, we have done over a thousand successful band-to-sleeve conversions and we typically find fantastic success in most patients who undergo this procedure. While it is a little more complicated than a routine gastric sleeve, in experienced hands it can be done safely and most of the time in a single operation. Take a look at this video, recorded by Dr. Trace Curry at JourneyLite Surgery Center in Cincinnati, to learn more about band-to-sleeve conversion surgery!

40% Reduction in Risk of Death and Cardiac Complications After Weight Loss Surgery

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Recently the Cleveland Clinic published a paper in JAMA looking at 2300 patients who underwent weight loss surgery (gastric sleeve, gastric bypass, gastric band, or duodenal switch) compared to 11,500  matched patients with similar medical issues who did not have surgery.

The endpoint of the study was the occurrence of one of the following:  death, coronary artery events, cerebrovascular events, heart failure, atrial fibrillation, or kidney disease.  They looked at these patients over an 8 year period and their findings were striking:  patients who had one of the above weight loss surgeries were 40% less likely to  experience on of these major complications.

This study adds to a growing body of evidence that shows some amazing reductions in mortality (and various other serious medical issues) cause by obesity.

JourneyLite Physicians offers all of the procedures featured in this study, some of which can be done on an outpatient basis with minimal down time or missed work.  So schedule a consultation to meet with one of our experienced weight loss surgeons in Ohio and start on a pathway to a healthier life now!

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