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The Policy VaultThe Policy Vault

diethylpropion — Blue Cross Blue Shield of Oklahoma

obesity

Initial criteria

  • Patient has participated in a weight loss regimen including low-calorie diet, increased physical activity, and behavioral modifications for ≥ 6 months prior to therapy AND
  • Patient will continue such weight loss regimen during therapy AND
  • IF pediatric (age 12 to < 18 years):
  • - Diagnosis of obesity confirmed by pretreatment BMI ≥ 95th percentile for age and gender OR BMI ≥ 30 kg/m^2 OR BMI ≥ 85th percentile with ≥ 1 weight-related comorbidity (e.g., hypertension, dyslipidemia, type 2 diabetes, or obstructive sleep apnea) AND
  • - Low-calorie diet, physical activity, and behavioral modification regimen for ≥ 6 months prior to therapy AND will continue regimen AND
  • IF patient has an FDA-labeled indication: patient’s age is within FDA labeling for that indication OR there is support for use for the patient’s age AND
  • ONE of the following agent-specific criteria:
  • • Requested agent is benzphetamine, diethylpropion, phendimetrazine, or phentermine OR
  • • Requested agent is Qsymia AND (dose 3.75mg/23mg OR patient is continuing Qsymia >3.75mg/23mg dose AND (pediatric ≥5% BMI reduction OR adult ≥5% weight loss from baseline OR received <14 weeks therapy OR dose titrating upward OR <12 weeks on 15mg/92mg strength OR therapy supported for this dose)) OR
  • • Requested agent is Contrave AND (new start OR currently treated <16 weeks OR ≥5% weight loss from baseline) OR
  • • Requested agent is Xenical (or Orlistat) AND ((age 12–16 years AND (new start OR <12 weeks therapy OR ≥4% weight loss from baseline)) OR (age ≥17 years AND (new start OR <12 weeks therapy OR ≥5% weight loss from baseline))) AND
  • Patient will NOT use requested agent in combination with another weight loss agent (e.g., Contrave, phentermine, Qsymia, Xenical, Saxenda, Wegovy, Zepbound) AND
  • Patient does NOT have any FDA-labeled contraindications to the requested agent

Reauthorization criteria

  • Patient previously approved for requested agent through plan's prior authorization AND
  • Patient meets one of the following:
  • • Has achieved and maintained ≥5% weight loss from baseline OR
  • • Requested agent is Qsymia AND (pediatric achieved and maintained ≥5% BMI reduction OR adult achieved and maintained ≥5% weight loss OR (less than 5% loss AND dose titration upward with <12 weeks on 15mg/92mg strength)) OR
  • • Requested agent is Xenical (or Orlistat) AND (age 12–16 years with ≥4% weight loss from baseline OR age ≥17 years with ≥5% weight loss from baseline) AND
  • IF pediatric (12 to <18 years): current BMI >85th percentile for age and gender AND
  • Patient remains on low-calorie diet, increased physical activity, and behavioral modifications AND
  • Patient will NOT use requested agent in combination with another weight loss agent AND
  • Patient does NOT have any FDA-labeled contraindications

Approval duration

BCBSIL FI & HIM: 12 months; Others: 3 months; Renewal—Qsymia ≥5% loss: 12 months; <5% loss: 3 months; all other agents: 12 months