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benzphetamine — Blue Cross Blue Shield of Illinois

obesity

Initial criteria

  • Patient has been on a weight loss regimen of a low-calorie diet, increased physical activity, and behavioral modifications for a minimum of 6 months prior to initiating therapy with the requested agent AND is currently on and will continue such regimen
  • If patient is pediatric (age 12 to <18 years), then ALL: (a) diagnosis of obesity confirmed by BMI ≥95th percentile for age and gender OR BMI ≥30 kg/m^2 OR BMI ≥85th percentile for age and gender with at least one weight-related comorbidity (e.g., hypertension, dyslipidemia, type 2 diabetes, or obstructive sleep apnea); (b) 6 months of prior weight loss regimen; (c) will continue the same regimen
  • If patient has an FDA labeled indication, then either (a) patient's age is within FDA labeling OR (b) there is support for use for the patient's age for the requested indication
  • Requested agent is one of the following and meets criteria:
  • A. benzphetamine, diethylpropion, phendimetrazine, or phentermine
  • B. Qsymia: dose 3.75mg/23mg OR patient already treated and dose >3.75/23mg AND (pediatric 5% BMI reduction OR adult 5% weight loss OR received <14 weeks of therapy OR dose titrated upward OR <12 weeks on 15mg/92mg strength OR support for requested dose)
  • C. Contrave: (1) newly starting therapy OR (2) currently treated <16 weeks OR (3) weight loss ≥5% from baseline
  • D. Xenical (or Orlistat): (1) ages 12–16 years: newly starting OR <12 weeks treated OR weight loss ≥4% from baseline; OR (2) age ≥17 years: newly starting OR <12 weeks treated OR weight loss ≥5% from baseline)
  • Patient will NOT be using another weight loss agent in combination (e.g., Contrave, phentermine, Qsymia, Xenical, Saxenda, Wegovy, Zepbound) AND patient does NOT have FDA labeled contraindications to the requested agent

Reauthorization criteria

  • Patient previously approved for the requested agent through plan’s PA process
  • Patient meets one of the following:
  • A. Has achieved and maintained ≥5% weight loss from baseline OR
  • B. Qsymia: pediatric (12–<18): ≥5% BMI reduction OR adult: ≥5% weight loss; OR weight loss <5% with dose titrated upward (on lower strengths) and <12 weeks on 15mg/92mg strength OR
  • C. Xenical (or Orlistat): age 12–16 years with maintained >4% weight loss OR age ≥17 years with maintained ≥5% weight loss
  • If pediatric (12–<18), current BMI >85th percentile for age and gender
  • Patient is currently on and will continue weight loss regimen (low-calorie diet, physical activity, behavioral modifications)
  • Patient not using another weight loss agent concurrently
  • No FDA labeled contraindications to requested agent

Approval duration

3–12 months