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benzphetamine — Blue Cross Blue Shield of New Mexico

weight management

Initial criteria

  • Patient has participated in a weight loss regimen of a low-calorie diet, increased physical activity, and behavioral modifications for ≥6 months prior to initiating therapy AND currently on and will continue such regimen.
  • Adult: age ≥18 years AND pretreatment BMI ≥30 kg/m^2 OR ≥27 kg/m^2 with at least one weight-related comorbidity (e.g., hypertension, dyslipidemia, type 2 diabetes, or obstructive sleep apnea).
  • Pediatric: age 12–<18 years AND ONE of the following: (1) BMI ≥95th percentile for age and gender; OR (2) BMI ≥30 kg/m^2; OR (3) BMI ≥85th percentile with ≥1 comorbidity (e.g., hypertension, dyslipidemia, type 2 diabetes, or obstructive sleep apnea).
  • If patient has an FDA-labeled indication, ONE of: (A) patient's age is within FDA labeling; OR (B) there is clinical support for use at patient's age.
  • ONE of the following: (A) requested agent is benzphetamine, diethylpropion, phendimetrazine, or phentermine; OR (B) requested agent is Qsymia and dose criteria met: (1) 3.75mg/23mg OR (2) ≥3.75mg/23mg with evidence of ≥5% baseline weight loss (adult) or ≥5% BMI reduction (pediatric), OR received less than 14 weeks of therapy, OR dose titration, OR <12 weeks on 15mg/92mg, OR support for therapy at requested dose; OR (C) requested agent is Contrave and agent-specific criteria met (new start, <16 weeks treatment, or ≥5% baseline weight loss achieved); OR (D) requested agent is Xenical (Orlistat) and agent-specific criteria met: (1) age 12–16 years with new start OR <12 weeks therapy OR ≥4% baseline weight loss; OR (2) age ≥17 years with new start OR <12 weeks therapy OR ≥5% baseline weight loss.
  • Patient will NOT be using the requested agent in combination with another weight loss agent (e.g., Contrave, phentermine, Qsymia, Xenical, Saxenda, Wegovy, Zepbound).
  • No FDA labeled contraindications to the requested agent.

Reauthorization criteria

  • Previously approved for requested agent through the plan’s prior authorization process.
  • Patient meets ONE of: (A) achieved and maintained ≥5% weight loss from baseline (adult); OR (B) Qsymia-specific: pediatric achieved ≥5% BMI reduction OR adult ≥5% weight loss OR in upward titration phase (<12 weeks on 15mg/92mg strength); OR (C) Xenical (Orlistat)-specific: age 12–16 years with ≥4% weight loss OR age ≥17 years with ≥5% weight loss.
  • If pediatric (12–<18 years), current BMI >85th percentile for age and gender.
  • Currently continuing low-calorie diet, increased physical activity, and behavioral modifications.
  • Not using any other weight loss agent concurrently (e.g., Contrave, phentermine, Qsymia, Xenical, Saxenda, Wegovy, Zepbound).
  • No FDA labeled contraindications to the requested agent.

Approval duration

BCBSIL FI & HIM: 12 months; all other plans: 3 months; renewal: Qsymia adults/pediatrics meeting ≥5% criteria: 12 months; Qsymia <5%: 3 months; all other agents: 12 months