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phendimetrazine — Blue Cross Blue Shield of Montana

obesity

Initial criteria

  • Adult patient AND has a diagnosis of obesity confirmed by BMI ≥ 30 kg/m^2 OR BMI ≥ 27 kg/m^2 with at least one weight-related comorbidity (hypertension, dyslipidemia, type 2 diabetes or obstructive sleep apnea)
  • Patient has been on a weight loss regimen of low-calorie diet, increased physical activity, and behavioral modifications for a minimum of 6 months prior to initiating therapy AND will continue regimen during therapy
  • Pediatric patient (age 12 to <18 years) AND ALL: diagnosis of obesity (BMI ≥95th percentile for age/gender OR BMI ≥30 kg/m^2 OR BMI ≥85th percentile with at least one comorbidity such as hypertension, dyslipidemia, type 2 diabetes, or obstructive sleep apnea), has been on a weight loss regimen for a minimum of 6 months, will continue regimen
  • If patient has FDA labeled indication: EITHER age within FDA labeling for requested indication OR support for use at requested age
  • ONE of the following applies: (A) Requested agent is benzphetamine, diethylpropion, phendimetrazine, or phentermine; OR (B) Requested agent is Qsymia AND (1) dose 3.75mg/23mg OR (2) patient currently treated, dose >3.75mg/23mg AND meets one of—(a) pediatric patient achieved ≥5% reduction in baseline BMI OR (b) adult achieved and maintained ≥5% weight loss OR (c) patient received <14 weeks therapy OR (d) dose being titrated upward OR (e) received <12 weeks on 15mg/92mg strength OR (f) support for therapy at requested dose; OR (C) Requested agent is Contrave AND one of—(1) newly starting therapy OR (2) currently treated <16 weeks OR (3) achieved and maintained ≥5% weight loss; OR (D) Requested agent is Xenical (or Orlistat) AND one of—(1) age 12–16 AND (a) newly starting OR (b) treated <12 weeks OR (c) achieved ≥4% weight loss OR (2) age ≥17 AND (a) newly starting OR (b) treated <12 weeks OR (c) achieved ≥5% weight loss)
  • Patient will NOT be using requested agent in combination with another weight loss agent (Contrave, phentermine, Qsymia, Xenical, Saxenda, Wegovy, Zepbound)
  • Patient does NOT have any FDA labeled contraindications to requested agent

Reauthorization criteria

  • Patient previously approved for requested agent through plan’s prior authorization
  • Patient meets one of—(A) achieved and maintained ≥5% weight loss from baseline OR (B) requested agent is Qsymia AND (1) for pediatric (12 to <18 years), achieved ≥5% reduction in baseline BMI OR (2) for adult achieved ≥5% weight loss OR (3) BOTH (a) pediatrics/adults achieved <5% reduction and (b) dose is being titrated upward (3.75 mg/23 mg, 7.5 mg/46 mg, or 11.25 mg/69 mg strengths only) AND (c) received <12 weeks therapy on 15mg/92mg strength OR (C) requested agent is Xenical (or Orlistat) AND (1) age 12–16 and achieved ≥4% weight loss OR (2) age ≥17 and achieved ≥5% weight loss
  • If pediatric (age 12 to <18 years), current BMI >85th percentile for age and gender
  • Patient currently on and will continue low-calorie diet, increased activity, behavioral modification regimen
  • Patient will not use requested agent with another weight loss agent (Contrave, phentermine, Qsymia, Xenical, Saxenda, Wegovy, Zepbound)
  • Patient does not have any FDA labeled contraindications to requested agent

Approval duration

BCBSIL FI & HIM: 12 months; All other plans: 3 months (initial); Renewal: Qsymia ≥5% response 12 months, <5% response 3 months; all other agents 12 months