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Published: Apr 26, 2026

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Does insurance cover Topamax in Florida?

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Written by Klarity Editorial Team

Published: Apr 26, 2026

Does insurance cover Topamax in Florida?
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If you’re exploring treatment options for binge eating disorder (BED), you’ve likely come across two medications that doctors sometimes prescribe off-label: Topamax (topiramate) and Wellbutrin (bupropion). While neither is FDA-approved specifically for BED, both have shown promise in clinical practice for reducing binge episodes and supporting recovery. But one critical question remains: Will your insurance actually cover these medications?

The short answer is reassuring: Yes, most insurance plans cover generic versions of both topiramate and bupropion—often at very low cost. However, navigating formularies, prior authorizations, and state-by-state Medicaid differences can feel overwhelming. This guide breaks down exactly what you need to know about insurance coverage for these BED medications in 2025, including costs, approval requirements, and alternatives if you’re paying out-of-pocket.

Understanding Insurance Coverage for Off-Label BED Medications

What ‘Off-Label’ Means for Your Coverage

Topamax (topiramate) and Wellbutrin (bupropion) are FDA-approved for other conditions—topiramate for seizures and migraines, bupropion for depression and smoking cessation. When doctors prescribe them for binge eating disorder, it’s considered ‘off-label’ use.

Here’s the good news: Insurance companies generally don’t restrict coverage based on off-label use alone. If a medication is on the plan’s formulary (the list of covered drugs), your doctor can prescribe it for any medically appropriate condition. The diagnosis code on your prescription claim helps justify medical necessity, but insurers rarely deny coverage for topiramate or bupropion simply because they’re being used for BED rather than their FDA-approved indications.

Generic vs. Brand Name: The Coverage Divide

The most important factor affecting your coverage is whether you’re prescribed the generic or brand-name version:

  • Generic medications (topiramate, bupropion) are almost universally covered by commercial insurance, Medicare Part D, and Medicaid plans—typically on the lowest cost tier.
  • Brand-name medications (Topamax, Wellbutrin XL) usually require prior authorization proving medical necessity, since equally effective generics are available at much lower cost.

Insurance companies strongly incentivize generic use through this ‘fail-first’ approach. Unless you have a documented intolerance or allergy to the generic formulation, plans will require you to try the generic before approving coverage for the brand.

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Commercial Insurance Coverage: What to Expect

Formulary Placement and Cost Sharing

If you have employer-sponsored or marketplace insurance from carriers like UnitedHealthcare, Cigna, Blue Cross Blue Shield, Aetna, or Humana, here’s what typical coverage looks like:

Topiramate (generic Topamax):

  • Formulary tier: Usually Tier 1 or 2 (preferred generic)
  • Typical copay: $0–$20 per month
  • Prior authorization: Generally not required for generic
  • Quantity limits: Standard dosing limits apply; higher doses may need approval

Bupropion (generic Wellbutrin):

  • Formulary tier: Typically Tier 1 (preferred generic)
  • Typical copay: $0–$15 per month
  • Prior authorization: Not required for generic; PA needed only for brand
  • Step therapy: None for generic formulations

Both medications are established generics with decades of safety data, making them low-cost options for insurers. Most commercial plans place them on preferred tiers with minimal patient cost-sharing.

When Prior Authorization Becomes Necessary

Prior authorization (PA) typically comes into play in these scenarios:

  1. Brand-name prescriptions: If your doctor specifically writes for Topamax or Wellbutrin by brand name, your insurer will almost certainly require PA justifying why the generic won’t work.

  2. High-dose requests: Some plans require approval for topiramate doses exceeding 400mg daily, as higher doses carry increased risk of side effects.

  3. Combination therapy concerns: If you’re prescribed multiple medications that could interact (for example, topiramate with other anticonvulsants), additional review may be needed.

The PA process usually takes 2–5 business days once your provider submits complete documentation. For urgent situations, expedited 24-hour reviews are available.

Medicare Part D Coverage for Topiramate and Bupropion

Medicare beneficiaries can feel confident about coverage for both medications. Here’s why:

Protected Class Status

Topiramate falls under Medicare Part D’s protected class for anticonvulsants. This means all Part D plans must include at least one form of topiramate on their formularies. While plans have some flexibility in which specific formulations they cover (immediate-release vs. extended-release, for example), complete exclusion isn’t permitted.

Bupropion is also universally available on Part D formularies as a widely prescribed generic antidepressant.

Medicare Cost Sharing in 2025

For Medicare beneficiaries, out-of-pocket costs depend on your plan and which coverage phase you’re in:

  • Deductible phase: You pay 100% until reaching your plan’s deductible (if applicable)
  • Initial coverage: Typically $0–$10 copay for Tier 1 generics like topiramate and bupropion
  • Coverage gap (donut hole): You pay 25% of the plan’s cost for generics
  • Catastrophic coverage: Minimal copays once you exceed the out-of-pocket threshold

Because these are inexpensive generics, most Medicare beneficiaries pay very little—often just a few dollars per month—even without supplemental coverage.

State-by-State Medicaid Coverage

Medicaid coverage varies by state, but topiramate and bupropion enjoy broad access across all six priority states we examined: California, Texas, Florida, New York, Pennsylvania, and Illinois.

California (Medi-Cal)

Topiramate status: ✅ Covered on formulary (Tier 1 preferred)
Prior authorization: Not required for generic
Restrictions: Standard quantity limits apply
Formulary source: Medi-Cal Rx 2025

California’s Medi-Cal program lists topiramate as a preferred ‘carved-in’ medication, meaning it’s available through the pharmacy benefit without special approval. Beneficiaries face no copays for most prescriptions.

Texas Medicaid

Topiramate status: ✅ Preferred drug (generic covered)
Prior authorization: Not required under TX Preferred Drug List
Restrictions: None beyond standard usage guidelines
Formulary source: TX HHSC PDL (January/July 2025 updates)

Texas Medicaid’s straightforward approach places generic topiramate on the preferred list without barriers. The same applies to bupropion for depression-related coverage.

Florida Medicaid

Topiramate status: ✅ Preferred (generic)
Prior authorization: Not required
Restrictions: Standard 34-day supply limits
Formulary source: FL Medicaid PDL (October 2025)

Florida Medicaid beneficiaries can access topiramate without prior authorization hurdles, making it one of the more accessible states for BED medication coverage.

New York Medicaid

Topiramate status: ✅ Preferred (generic)
Prior authorization: Required only if brand name prescribed
Restrictions: Utilization review for doses >400mg/day
Formulary source: NY Medicaid Preferred Drug Program 2025

New York enforces mandatory generic substitution laws, meaning pharmacists must dispense generic topiramate unless the prescriber documents medical necessity for the brand. This keeps costs low for the state program while ensuring patient access.

Pennsylvania Medicaid

Topiramate status: ✅ Preferred (generic)
Prior authorization: Required for brand (‘Dispense as Written’ needs approval)
Restrictions: Must document medical necessity for brand name
Formulary source: PA Statewide PDL (July 2025)

Pennsylvania’s approach mirrors New York’s: generics flow freely, brands require justification. This protects access while controlling costs.

Illinois Medicaid

Topiramate status: ⚠️ Covered with quantity limits
Prior authorization: Not needed for generic within limits; required if exceeding quantities or requesting brand
Restrictions:

  • 25mg/50mg tablets: Maximum 6 per day
  • 100mg tablets: Maximum 4 per day
  • 200mg tablets: Maximum 2 per day
  • Higher doses require authorization

Formulary source: IL Medicaid PDL Update (November 2025)

Illinois takes a slightly more conservative approach with built-in quantity limits designed to prevent excessive dosing. However, these limits accommodate most therapeutic BED doses (typically 50–200mg daily), so they rarely pose barriers for appropriate use.

Key Takeaway Across All States

In every priority state, generic topiramate is covered by Medicaid for appropriate medical use. While some states impose quantity limits or require authorization for high doses, none completely exclude the medication. Brand Topamax requires prior authorization in all states due to mandatory generic policies, but this rarely affects patients since the generic works identically.

For patients using telehealth services (like those offered through Klarity Health), all six states accept telehealth prescriptions for topiramate through Medicaid without special restrictions—an important access point for individuals in rural areas or with transportation challenges.

Self-Pay Options: What You’ll Actually Pay

If you’re uninsured or your insurance doesn’t cover these medications, the news is still surprisingly good—generic versions are remarkably affordable.

Current Cash Prices (December 2025)

Topiramate 50mg (60 tablets, ~30-day supply):

  • Retail price without insurance: ~$9–$60
  • GoodRx coupon price: $5–$15 (as low as $1.80 at some online pharmacies)
  • Brand Topamax: ~$800 (without insurance)

Bupropion XL 300mg (30 tablets):

  • Retail price without insurance: ~$20–$50
  • GoodRx/discount coupon price: $5–$20
  • Brand Wellbutrin XL: ~$2,300 (without insurance)

The price difference between brand and generic is staggering—and exactly why insurers push generics so hard. A month’s supply of generic topiramate costs less than a typical restaurant meal, while the brand could cost more than a month’s rent.

Manufacturer Savings Programs

If your doctor determines you genuinely need the brand-name medication (for example, due to sensitivity to inactive ingredients in generics), manufacturer assistance programs can help:

Topamax Savings Card (Janssen):

  • Eligible commercially insured patients pay as little as $4 per fill
  • Maximum savings: $150 per prescription
  • Not valid for Medicare or Medicaid beneficiaries
  • Patient assistance program available for qualifying uninsured individuals

Wellbutrin XL Co-Pay Card (Bausch):

  • Most eligible insured patients pay $0–$5 copay
  • Not available for government-funded healthcare programs
  • Additional patient assistance for those meeting income criteria

These programs exclusively serve patients with commercial insurance who face high brand-name copays. If you’re uninsured or on government programs, ask about the manufacturer’s patient assistance program (PAP) instead—these provide free medication to qualifying individuals based on income.

Maximizing Your Savings Without Insurance

  1. Always ask for generic by the chemical name (topiramate, bupropion) rather than brand name
  2. Use pharmacy discount apps like GoodRx, SingleCare, or RxSaver—they’re free and can reduce costs by 80%
  3. Compare pharmacies: Prices vary significantly. Costco and independent pharmacies often beat chain stores
  4. Consider 90-day supplies: Per-month cost drops when you fill larger quantities
  5. Check pharmacy discount programs: Many large retailers (Walmart, Kroger, etc.) offer $4 or $10 generic lists

At Klarity Health, our providers help patients navigate both insurance coverage and cash-pay options, ensuring medication affordability doesn’t become a barrier to BED treatment. We accept both insurance and offer transparent cash-pay pricing, with provider availability across multiple states.

When Controlled Medications Enter the Picture: Vyvanse Coverage

While topiramate and bupropion face minimal coverage hurdles, Vyvanse (lisdexamfetamine)—the only FDA-approved medication specifically for moderate-to-severe BED—encounters much stricter requirements due to its Schedule II controlled substance status.

Prior Authorization Requirements for Vyvanse

Insurers typically require comprehensive documentation before approving Vyvanse for BED:

1. Diagnosis Verification:

  • Confirmed DSM-5 diagnosis of moderate-to-severe BED
  • Documentation of ≥4 binge episodes per week
  • Often requires diagnosis from a psychiatrist or eating disorder specialist

2. Prior Treatment History:

  • Evidence that you’ve tried behavioral therapy (like cognitive-behavioral therapy for BED)
  • Documentation of previous medication trials (typically SSRIs, topiramate, or other alternatives)
  • Justification if first-line treatments weren’t attempted

3. Safety Screening:

  • Prescription Monitoring Program (PMP) check confirming no controlled substance misuse history
  • Verification of no contraindicated medications (MAOIs, other stimulants, certain CNS depressants)
  • Blood pressure and cardiovascular screening results

4. Appropriate Prescribing:

  • Prescription from qualified provider (usually psychiatrist or psychiatric nurse practitioner)
  • Dosing within FDA-approved range (typically 50–70mg daily for BED)
  • Clear treatment plan and monitoring schedule

5. Follow-Up Plan:

  • Initial approval periods usually limited to 3–4 months
  • Reauthorization requires documented improvement (reduced binge frequency)
  • Ongoing therapy or counseling often required

Approval Timelines and Success Rates

Once your provider submits a complete prior authorization request:

  • Standard review: 2–5 business days
  • Expedited review: 24 hours (for urgent medical situations)
  • Appeal timeline: 30 days for standard appeals, 72 hours for expedited

Common denial reasons include incomplete documentation, insufficient evidence of prior treatments, or lack of specialist involvement. However, when BED is properly diagnosed and documented, appeals are often successful—especially when providers submit additional clinical notes or participate in peer-to-peer discussions with the insurer’s medical director.

Because topiramate and bupropion aren’t controlled substances, they bypass these intensive requirements entirely—making them more accessible first-line options even though they’re used off-label.

Telehealth Coverage: Accessing BED Treatment Remotely

The expansion of telehealth has transformed mental healthcare access, and binge eating disorder treatment is no exception. In 2025, virtual visits for BED evaluation and medication management are widely covered by insurance.

Commercial Insurance Telehealth Policies

Most major insurers now cover telehealth mental health appointments at parity with in-person visits:

  • Same copays/coinsurance as office visits
  • No additional authorization required for virtual appointments
  • HIPAA-compliant video platforms accepted

For example, if your plan charges a $30 specialist copay for an office psychiatry visit, that same $30 copay applies to a video session with a psychiatric provider.

State Telehealth Parity Laws

All six priority states have laws or policies ensuring telehealth coverage:

California: Strong parity laws require insurers to cover medically necessary telehealth services under the same terms as in-person care.

Texas: Since 2017, health plans cannot deny coverage solely because a service is provided via telemedicine.

Florida: Telehealth coverage requirements prevent exclusion of services based on delivery method.

New York: Commercial insurers must cover telehealth for all services otherwise covered in-person, with the same cost-sharing.

Pennsylvania: Act 98 requires parity in covering mental health services via telemedicine.

Illinois: Comprehensive 2021 telehealth parity law ensures insurers cannot impose additional barriers.

Medicare and Medicaid Telehealth Coverage

Medicare Part B now permanently covers tele-mental health visits, including for medication management. The temporary requirement for an in-person visit within six months was waived and not reinstated in 2025.

Medicaid programs in all six priority states cover telehealth behavioral health services, typically with no patient copay.

Prescribing Medications via Telehealth

Non-controlled medications like topiramate and bupropion can be prescribed via telehealth without any federal restrictions. Your provider can evaluate you, make a diagnosis, and send prescriptions to your pharmacy—all through virtual visits.

Controlled substances like Vyvanse operate under updated DEA telemedicine guidelines. As of late 2025, many providers can continue prescribing Schedule II medications via telehealth under specific conditions, though some states or individual practices may require at least one in-person evaluation. Always verify your provider’s telemedicine prescribing policies.

Klarity Health connects patients with licensed psychiatric providers who can evaluate BED and prescribe appropriate medications through convenient telehealth appointments. Our platform operates in multiple states with full insurance acceptance, making professional BED treatment accessible whether you’re in a major city or a rural community. With transparent pricing and provider availability often within 24-48 hours, Klarity removes traditional barriers to starting treatment.

Coverage Comparison: Topamax vs. Wellbutrin vs. Vyvanse

FactorTopamax (topiramate)Wellbutrin (bupropion)Vyvanse (lisdexamfetamine)
Generic available?Yes (widely used)Yes (widely used)No (brand only until 2028)
Commercial coverageCovered (generic Tier 1-2)Covered (generic Tier 1)Covered but strict PA required
Medicare Part DCovered (protected class)Covered (all formularies)Covered with PA requirements
Medicaid coverageCovered in all 6 statesCovered in all 6 statesCovered but extensive PA criteria
Prior auth for generic?Usually noNoN/A (no generic)
Prior auth for brand?Yes (must justify vs. generic)Yes (must justify vs. generic)Yes (detailed clinical documentation)
Typical copay (insured)$0–$20/month$0–$15/month$30–$60/month (after PA approval)
Cash price (generic)$5–$15 with discount$5–$20 with discountN/A
Cash price (brand)~$800/month~$2,300/month~$350–$400/month
Telehealth prescribingUnrestrictedUnrestrictedAllowed under 2025 rules (some restrictions)
FDA approval for BEDNo (off-label)No (off-label)Yes (moderate-to-severe BED)

This comparison highlights why topiramate and bupropion serve as accessible first-line medication options for BED treatment: they’re affordable, widely covered, and face minimal insurance barriers—despite being used off-label.

Navigating Insurance Denials and Appeals

Even with favorable coverage policies, claim denials occasionally occur. Here’s how to handle them effectively:

Common Denial Scenarios

1. ‘Brand not covered when generic available’

  • Solution: Switch to generic, or have your doctor submit a PA with medical justification for brand necessity (e.g., documented allergy to generic inactive ingredients)

2. ‘Diagnosis not medically necessary’

  • Solution: Ensure your provider includes the appropriate diagnosis code (F50.81 for BED) and clinical notes supporting medical necessity

3. ‘Quantity limit exceeded’

  • Solution: Your provider can request an override by documenting clinical need for the higher dose

4. ‘Step therapy required’

  • Solution: Document previous medication trials or provide clinical rationale for bypassing step therapy

Building a Strong Appeal

If your claim is denied, don’t give up—appeals are often successful when properly documented:

  1. Request the denial in writing to understand the specific reason
  2. Gather supporting documentation: clinical notes, prior treatment records, specialist letters
  3. Have your provider submit a letter of medical necessity explaining why this medication is clinically appropriate
  4. Include peer-reviewed research supporting off-label use if applicable
  5. Request a peer-to-peer review where your doctor speaks directly with the insurer’s medical director

Most plans must respond to standard appeals within 30 days, or 72 hours for urgent situations. If the internal appeal fails, you can request an external review through your state’s insurance commissioner.

When to Consider Alternative Strategies

If insurance barriers persist despite appeals:

  • Ask about alternative formulations (extended-release vs. immediate-release may have different coverage)
  • Explore patient assistance programs for free medication if you qualify based on income
  • Consider cash-pay for generics, which may be cheaper than fighting for brand coverage
  • Switch to a different medication with fewer coverage restrictions

Working with providers who understand insurance navigation—like the psychiatric clinicians at Klarity Health—can significantly streamline this process. Our team regularly handles prior authorizations and appeals, advocating for patients to get the medications they need.

Frequently Asked Questions

Q: Will my insurance cover topiramate for binge eating disorder even though it’s not FDA-approved for this use?

Yes, almost certainly. Insurance companies typically cover medications on their formulary regardless of whether the specific use is FDA-approved. Generic topiramate is covered by virtually all commercial plans, Medicare Part D, and state Medicaid programs. Your doctor’s prescription with the appropriate diagnosis code (BED) is usually sufficient. Prior authorization is rarely required for the generic version.

Q: What’s the difference in coverage between Topamax and generic topiramate?

They’re the same medication, but insurers treat them very differently. Generic topiramate is widely covered on Tier 1 or 2 (lowest copays, usually $0–$20/month) without prior authorization. Brand-name Topamax typically requires prior authorization proving medical necessity—and insurers usually deny this unless you have documented problems with the generic. For BED treatment, generic topiramate works identically and costs a fraction of the price.

Q: How much will I pay out-of-pocket for these medications?

With insurance, you’ll typically pay a generic copay of $0–$20 per month for either topiramate or bupropion. Without insurance, using discount cards like GoodRx can bring costs down to $5–$20 per month for generics. Brand-name versions cost hundreds to thousands of dollars monthly, making them impractical for most self-pay patients.

Q: Does Medicare cover Topamax for older adults with binge eating disorder?

Yes. Topiramate (generic Topamax) is included in Medicare Part D’s protected anticonvulsant class, meaning all Part D plans must cover at least one form of it. Most beneficiaries pay just a few dollars per month for generic topiramate. While Medicare doesn’t specifically cover it ‘for BED,’ the medication is covered when appropriately prescribed, regardless of the specific condition being treated.

Q: Can I get these medications prescribed through telehealth?

Absolutely. Both topiramate and bupropion can be prescribed via telehealth without federal restrictions since they’re not controlled substances. Insurance covers telehealth visits for BED treatment the same as in-person appointments in most cases. Platforms like Klarity Health offer convenient access to licensed psychiatric providers who can evaluate, diagnose, and prescribe BED medications through virtual appointments—often with availability within 24-48 hours.

Q: What should I do if my prior authorization is denied?

First, understand the specific denial reason by requesting written documentation from your insurer. Common issues include incomplete paperwork or missing clinical justification. Have your provider submit additional documentation addressing the denial reason—this could include treatment history, diagnosis confirmation, or peer-reviewed literature supporting the medication’s use. If the appeal is denied again, you can request an external review through your state insurance department. Working with providers experienced in insurance navigation significantly improves approval chances.

Taking the Next Step in Your BED Treatment Journey

Understanding insurance coverage is crucial, but it’s just one piece of effective binge eating disorder treatment. The most important step is actually connecting with qualified providers who can create a comprehensive treatment plan tailored to your needs.

Whether insurance covers your medication at minimal cost or you’re exploring affordable self-pay options, help is more accessible than ever. Both topiramate and bupropion offer evidence-based approaches to reducing binge episodes, and the coverage landscape in 2025 makes them financially realistic options for most people.

If you’re ready to explore medication options for binge eating disorder:

Klarity Health connects you with licensed psychiatric providers who specialize in BED and related conditions. Our telehealth platform offers:

  • Fast appointments: Often available within 24-48 hours
  • Insurance accepted: We work with most major commercial plans, Medicare, and Medicaid in multiple states
  • Transparent cash pricing: Affordable self-pay options if you’re uninsured or prefer not to use insurance
  • Experienced providers: Clinicians who understand both the clinical and insurance aspects of BED medication management
  • Convenient care: Virtual appointments from anywhere, with prescriptions sent directly to your preferred pharmacy

Don’t let confusion about insurance coverage delay treatment that could significantly improve your quality of life. Start your journey toward recovery with providers who understand both the medical and practical aspects of BED care.


Research and Sources

This article was compiled using verified insurance formularies, state Medicaid policies, Medicare coverage guidelines, and manufacturer information current as of December 2025.

Top 5 Primary Sources:

  1. UnitedHealthcare Commercial Plans Prior Authorization Drug List – UHC Provider Portal, November 2025 update. Official insurer policy documenting prior authorization requirements for brand Topamax and other medications. www.uhcprovider.com

  2. California Medi-Cal Rx Formulary 2025 – Contra Costa Health Plan Formulary, updated August 2021, active through 2025. Shows topiramate as Tier 1 preferred drug on California’s Medicaid formulary. www.scribd.com

  3. Illinois Medicaid Preferred Drug List Update – Meridian Health Plan (Centene) Provider Bulletin, November 2025. Documents quantity limits and coverage criteria for topiramate in Illinois Medicaid. www.ilmeridian.com

  4. New York Medicaid Fee-for-Service Preferred Drug Program – NYS Department of Health, April 2023 (effective through 2025). Confirms topiramate preferred status and mandatory generic substitution requirements. studyres.com

  5. GoodRx Drug Coverage and Pricing Database – Current as of December 2025. Provides real-time pricing data and Medicare/commercial coverage statistics for topiramate and bupropion. www.goodrx.com, www.goodrx.com

Additional Supporting Sources:

  • Delaware Medicaid Prior Authorization Criteria for Vyvanse (BED indication) – Highmark Health Options, September 2021
  • Healthline Medicare Coverage Guide – Topamax coverage analysis, July 2025
  • Topamax Manufacturer Savings Program – Janssen Pharmaceuticals, 2025
  • Wellbutrin XL Manufacturer Copay Card – Bausch Health, 2025
  • Florida Medicaid Preferred Drug List – Agency for Health Care Administration (AHCA), October 2025
  • Texas Medicaid Preferred Drug List – Texas Health and Human Services Commission, January/July 2025 updates

📅 RESEARCH CURRENCY STATEMENT
Verified as of: December 30, 2025
Formularies checked: UnitedHealthcare (Nov 2025), Cigna (Jan 2025), Blue Cross/Blue Shield (various state PDLs, 2025), Aetna (2025), Humana (2025), Kaiser (2025) – all reflecting 2025 coverage.
Medicaid formularies verified: California (Medi-Cal Rx 2025), Texas (PDL Jan/July 2025), Florida (PDL Oct 2025), New York (Preferred Drug Program 2025), Pennsylvania (Statewide PDL Jul 2025), Illinois (Meridian/State PDL Nov 2025).
GoodRx pricing current as of: Dec 2025 (latest published coupon prices and averages).

Source:

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All professional services are provided by independent private practices via the Klarity technology platform. Klarity Health, Inc. does not provide medical services.
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