The Qsymia Savings Card

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Please complete the following form. Note: all fields are required.

I am a:

Patient who is 18 years of age or older

Caregiver of a patient who is under 18 years of age

VIVUS websites are intended for individuals 18 years of age or older. Any information collected on behalf of patients under 18 years of age must be provided by a legally authorized caregiver and not from a minor themselves.

By checking this box, I certify that I am 18 years of age or older. I understand and agree that the information I provide, as well as the information obtained about me regarding my VIVUS prescription from the pharmacy, will be shared with the manufacturer and any companies working with the manufacturer. I also agree that VIVUS may contact me in the future with information about Qsymia and/or additional patient support offers.

Get Your Qsymia Savings Card and Reminders by text message (Optional)
Please note that messages will be delivered from the sender QSYMIA (779642)

I agree to receive special offers from QSYMIA.

I agree to receive important updates and messages related to my account from QSYMIA.

By checking one or both of these boxes, I understand and agree to receive SMS messages from QSYMIA in connection with your Qsymia Savings Card, as described in the TERMS OF USE and PRIVACY POLICY, at the number I provide. Messages may include special offers and important updates.

I acknowledge that I can choose to stop receiving text messages at any time texting "STOP" to QSYMIA. To rejoin the SMS service, I can send "START" to QSYMIA opt back into the program. If experiencing issues with the messaging program, I can reply with the keyword “HELP” for help. Message frequency varies. Message and data rates may apply. Participating carriers: all U.S. based carriers.

I understand that I am not required to agree to receive text messages as a condition of signing up for a Qsymia Savings Card.

QSYMIA SAVINGS CARD — PATIENT ELIGIBILITY, TERMS AND CONDITIONS

Eligible patients for the monthly savings offer must reside in the United States, Washington, DC, Puerto Rico, Virgin Islands, or Guam, and be 18 years or older. If the eligible patient is 12-17 years of age, a caregiver must sign up on their behalf. This offer is limited to one per patient and may not be combined with any other offer. VIVUS LLC reserves the right to modify or discontinue these offers at any time without notice.

Prescriptions for Qsymia are redeemable only through Qsymia-certified pharmacies. Patients or caregivers are responsible for any sales tax. Patients or caregivers may not submit a claim for the amounts covered by the offer for payment to any third-party payers, including a flexible spending account (FSA), a Health Savings Account (HSA), or a Health Reimbursement Account (HRA). Patients or caregivers are responsible for reporting receipt of program benefit to any insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled, as may be required.

The Monthly Savings Offer card requires an activated Program ID prior to use.

A valid prescription for Qsymia is required at the time of redemption. No substitutions permitted.

Not available for individuals enrolled in any government-funded insurance program that covers prescription drugs (for example, Medicaid, Medicare, TRICARE, VA, Department of Defense, Indian Health Service) or where prohibited by law.

Patients paying cash or patients whose commercial insurance coverage does not cover Qsymia, are eligible to receive $75 off quantities of 28-30 days for up to 100 subsequent fills. Both of these groups are eligible to receive $70 off 3.75 mg/23 mg dose quantities of 14-15 days for up to 10 subsequent fills. Please note that quantity claims of 16-27 days will be rejected.

Commercially-insured patients with coverage for Qsymia are required to cover the first $70 of the copay. For quantities of 28-30 days, these patients are eligible to receive $65 off for up to 100 subsequent fills. For 3.75 mg/23 mg dose quantities of 14-15 days, these patients are eligible to receive $65 off for up to 10 subsequent fills. Please note that quantity claims of 16-27 days will be rejected.

It is illegal to sell, purchase, trade, or counterfeit, or offer to sell, purchase, trade, or counterfeit the cards. Void where prohibited by law, taxed, or restricted.

*Retail and Home Delivery Pharmacy - $75 is the average retail pharmacy price for a 30-day Rx for patients covered by commercial insurance after covering $70 copay. $134 is the average price for patients paying cash or if Qsymia is not covered by commercial insurance. Source: McKesson Specialty Health, calculated between Jan-Sep 2023. Pharmacy fees may vary by location. Patients with commercial insurance coverage are eligible to receive $65 off 3.75 mg/23 mg dose quantities of 14-15 days and all other doses with quantities of 28-30 days. Patients paying cash or if Qsymia is not covered by commercial insurance, can receive $70 off 3.75 mg/23 mg dose quantities of 14-15 days and $75 off all other doses with quantities of 28-30 days. Please note that quantity claims of 16-27 days are not eligible for the Qsymia Savings Card. See full terms and conditions. $98 home delivery pharmacy pricing includes 6-week New Patient Packs, 6-week Titration Packs and all 30-day prescriptions. Additional shipping and handling costs will apply. This is a cash only program - insurance claims will not be processed. Please see QsymiaEngage.com for full program details.

**IQVIA Reporting - July 2023

Indication

Qsymia should be used together with a reduced-calorie diet and increased physical activity for chronic weight management in:

Adults with an initial body mass index (BMI) of:
- 30 kg/m² or greater (obese) or
- 27 kg/m² or greater (overweight) in the presence of at least one weight-related medical condition such as high blood pressure, type 2 diabetes, or high cholesterol
Pediatric patients aged 12 years and older with an initial BMI in the 95th percentile or greater standardized for age and sex

LIMITATIONS OF USE:

It is not known if Qsymia changes your risk of heart problems or stroke or of death due to heart problems or stroke
It is not known if Qsymia is safe and effective when taken with other prescription, over-the-counter, or herbal weight loss products

Important Safety Information

Do not take Qsymia if you are pregnant, planning to become pregnant, or become pregnant during Qsymia treatment; have glaucoma; have thyroid problems (hyperthyroidism); are taking certain medicines called monoamine oxidase inhibitors (MAOIs) or have taken MAOIs in the past 14 days; are allergic to topiramate, sympathomimetic amines such as phentermine, or any of the ingredients in Qsymia. See the end of the Medication Guide for a complete list of ingredients in Qsymia.

QSYMIA CAN CAUSE SERIOUS SIDE EFFECTS, INCLUDING:

Birth defects (cleft lip/cleft palate). If you take Qsymia during pregnancy, your baby has a higher risk for birth defects called cleft lip and cleft palate. These defects can begin early in pregnancy, even before you know you are pregnant. Patients who are pregnant must not take Qsymia. Patients who can become pregnant should have a pregnancy test before taking Qsymia and every month while taking Qsymia and use effective birth control (contraception) consistently while taking Qsymia. Talk to your healthcare provider about how to prevent pregnancy.

If you become pregnant while taking Qsymia, stop taking Qsymia immediately, and tell your healthcare provider right away. Healthcare providers and patients should report all cases of pregnancy to FDA MedWatch at 1-800-FDA-1088, and the Qsymia Pregnancy Surveillance Program at 1-888-998-4887.

Qsymia may slow the increase in height in children 12 years and older.

Increases in heart rate. Qsymia can increase your heart rate at rest. Your healthcare provider should check your heart rate while you take Qsymia. Tell your healthcare provider if you experience, while at rest, a racing or pounding feeling in your chest lasting several minutes when taking Qsymia.

Visual field defects (independent of elevated intraocular pressure) have been reported in clinical trials and in postmarketing experience in patients receiving topiramate. In clinical trials, most of these events were reversible after topiramate discontinuation. If visual problems occur at any time during treatment, consider discontinuing Qsymia.

Suicidal thoughts or actions. Topiramate, an ingredient in Qsymia, may cause you to have suicidal thoughts or actions. Call your healthcare provider right away if you have any of these symptoms, especially if they are new, worse, or worry you: thoughts about suicide or dying; attempts to commit suicide; new or worse depression; new or worse anxiety; feeling agitated or restless; panic attacks; trouble sleeping (insomnia); new or worse irritability; acting aggressive, being angry, or violent; acting on dangerous impulses; an extreme increase in activity or talking (mania); other unusual changes in behavior or mood.

Serious eye problems, which include any sudden decrease in vision, with or without eye pain and redness or a blockage of fluid in the eye causing increased pressure in the eye (secondary angle closure glaucoma). These problems can lead to permanent vision loss if not treated. Tell your healthcare provider right away if you have any new eye symptoms.

Qsymia may cause a severe rash with blisters and peeling skin, especially around the mouth, nose, eyes, and genitals (Stevens-Johnson Syndrome). Qsymia may also cause a rash with blisters and peeling skin over much of the body that may be life threatening (Toxic Epidermal Necrolysis). Call your healthcare provider right away if you develop a skin rash or blisters.

COMMON SIDE EFFECTS OF QSYMIA IN ADULTS INCLUDE:

Numbness or tingling in the hands, arms, feet, or face (paraesthesia); dizziness; changes in the way foods taste or loss of taste (dysgeusia); trouble sleeping (insomnia); constipation; and dry mouth.

COMMON SIDE EFFECTS OF QSYMIA IN CHILDREN 12 YEARS OLD AND OLDER INCLUDE:

Depression, dizziness, joint pain, fever, flu, and ankle sprain.

POSSIBLE SIDE EFFECTS OF QSYMIA INCLUDE:

Mood changes and trouble sleeping. Qsymia may cause depression or mood problems, and trouble sleeping. Tell your healthcare provider if symptoms occur.

Concentration, memory, and speech difficulties. Qsymia may affect how you think and cause confusion, problems with concentration, attention, memory or speech. Tell your healthcare provider if symptoms occur.

Increases of acid in bloodstream (metabolic acidosis). If left untreated, metabolic acidosis can cause brittle or soft bones (osteoporosis, osteomalacia, osteopenia), kidney stones, can slow the rate of growth in children, and may possibly harm your baby if you are pregnant. Metabolic acidosis can happen with or without symptoms. Sometimes people with metabolic acidosis will: feel tired, not feel hungry (loss of appetite), feel changes in heartbeat, or have trouble thinking clearly. Your healthcare provider should do a blood test to measure the level of acid in your blood before and during your treatment with Qsymia.

Low blood sugar (hypoglycemia) in people with type 2 diabetes mellitus who also take medicines used to treat type 2 diabetes mellitus. Weight loss can cause low blood sugar in people with type 2 diabetes mellitus who also take medicines used to treat type 2 diabetes mellitus (such as insulin or sulfonylureas). You should check your blood sugar before you start taking Qsymia and while you take Qsymia.

High blood pressure medicines. If you are taking medicines for your blood pressure, your doctor may need to adjust these medicines while taking Qsymia.

Central Nervous System (CNS) side effects. The use of prescription sleep aids, anxiety medicines, or drinking alcohol with Qsymia may cause an increase in CNS symptoms such as dizziness and light-headedness. Do not drink alcohol with Qsymia.

Possible seizures if you stop taking Qsymia too fast. Seizures may happen in people who may or may not have had seizures in the past if you stop Qsymia too fast. Your healthcare provider will tell you how to stop taking Qsymia slowly.

Kidney stones. Drink plenty of fluids when taking Qsymia to help decrease your chances of getting kidney stones. If you get severe side or back pain, and/or blood in your urine, call your healthcare provider.

Decreased sweating and increased body temperature (fever). People should be watched for signs of decreased sweating and fever, especially in hot temperatures. Some people may need to be hospitalized for this condition.

Qsymia capsules contain the inactive ingredient FD&C Yellow No. 5 (tartrazine) which can cause allergic-type reactions (including bronchial asthma) in certain people, especially people who also have an allergy to aspirin.

Tell your healthcare provider if you have any side effect that bothers you or does not go away. These are not all of the possible side effects of Qsymia. For more information, ask your healthcare provider or pharmacist.

Call your doctor for medical advice about side effects. You may report side effects to VIVUS LLC at 1-888-998-4887 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

Please read the Qsymia Medication Guide, Full Prescribing Information and Risk of Birth Defects with Qsymia Patient Brochure.

References:

1. Qsymia Full Prescribing Information. Campbell, CA: VIVUS LLC; 2023. 2. Data on File. VIVUS LLC. 3. Kumar S, Kelly AS. Review of Childhood Obesity: From Epidemiology, Etiology, and Comorbidities to Clinical Assessment and Treatment. Mayo Clin Proc. 2017 Feb;92(2):251-265. 4. Cardel MI, Jastreboff AM, Kelly AS. Treatment of Adolescent Obesity in 2020. JAMA. 2019 Nov 5;322(17):1707-1708. 5. Centers for Disease Control (n.d.). Prevalence of Childhood Obesity in the United States. Retrieved from https://www.cdc.gov/obesity/data/childhood.html 6. Rush EC, Yan MR. Evolution not Revolution: Nutrition and Obesity. Nutrients. 2017 May 20;9(5):519. 7. Amin T, Mercer JG. Hunger and Satiety Mechanisms and Their Potential Exploitation in the Regulation of Food Intake. Curr Obes Rep. 2016 Mar;5(1):106-12. 8. Halford JCG, Bereket A, Bin-Abbas B, Chen W, Fernández-Aranda F, Garibay Nieto N, López Siguero JP, Maffeis C, Mooney V, Osorto CK, Reynoso R, Rhie YJ, Toro-Ramos M, Baur LA. Misalignment among adolescents living with obesity, caregivers, and healthcare professionals: ACTION Teens global survey study. Pediatr Obes. 2022 Jul 15:e12957. 9. Puhl RM, Himmelstein MS. Adolescent preferences for weight terminology used by health care providers. Pediatr Obes. 2018 Sep;13(9):533-540. 10. Pont SJ, Puhl R, Cook SR, Slusser W; SECTION ON OBESITY; OBESITY SOCIETY. Stigma Experienced by Children and Adolescents With Obesity. Pediatrics. 2017 Dec;140(6):e20173034. American Academy of Pediatrics. 11. Lessard LM, Puhl RM. Weight-based cybervictimization: Implications for adolescent health. Pediatr Obes. 2022 Jun;17(6):e12888. The study involved 452 U.S. adolescents aged 11–17 years old with an average age 14.91 years.

Indication

Qsymia is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management inadults with an initial body mass index (BMI)…

Important Safety Information

The Qsymia Savings Card

Get your Savings Card

Indication

Important Safety Information

Qsymia Savings Card - Patient Eligibility, Terms and Conditions