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phentermine — Blue Cross Blue Shield of Texas

weight loss

Initial criteria

  • Patient has been on a weight loss regimen (low-calorie diet, increased physical activity, behavioral modifications) for ≥ 6 months prior to initiating therapy AND will continue the regimen
  • Adult: diagnosis of obesity (BMI ≥ 30 kg/m^2) OR overweight with at least one weight-related comorbidity
  • Pediatric (age 12–<18 years): diagnosis of obesity confirmed by BMI ≥95th percentile for age/gender OR BMI ≥30 kg/m^2 OR BMI ≥85th percentile plus one comorbidity (hypertension, dyslipidemia, type 2 diabetes, or obstructive sleep apnea)
  • For all: age within FDA labeling for requested agent OR support for use at that age
  • Requested agent must be one of benzphetamine, diethylpropion, phendimetrazine, phentermine, Qsymia, Contrave, Xenical (Orlistat)
  • For Qsymia: dose 3.75mg/23mg OR patient currently on Qsymia with dose >3.75mg/23mg AND one of: ≥5% baseline BMI/weight loss or <14 weeks therapy or dose being titrated or <12 weeks on 15mg/92mg strength or supported for requested dose
  • For Contrave: patient newly starting OR currently treated with <16 weeks therapy OR ≥5% weight loss from baseline
  • For Xenical (Orlistat): age 12–16 years with newly starting OR <12 weeks therapy OR ≥4% weight loss from baseline OR age ≥17 years with newly starting OR <12 weeks therapy OR ≥5% weight loss from baseline
  • Patient will NOT use requested agent in combination with another weight-loss agent (Contrave, phentermine, Qsymia, Xenical, Saxenda, Wegovy, Zepbound)
  • Patient has no FDA labeled contraindications to the requested agent

Reauthorization criteria

  • Patient previously approved for requested agent through Prior Authorization
  • Patient achieved and maintained ≥5% weight loss from baseline OR for Qsymia: ≥5% reduction in BMI (pediatrics) or ≥5% weight loss (adults) OR <5% but dose titration upward (3.75mg/23mg, 7.5mg/46mg, 11.25mg/69mg) and <12 weeks at 15mg/92mg strength
  • For Xenical (Orlistat): age 12–16 years and ≥4% weight loss OR age ≥17 years and ≥5% weight loss
  • If pediatric (12–<18 years): current BMI >85th percentile for age/gender
  • Patient continues diet, activity, behavioral modification regimen
  • Patient not using concomitant weight-loss agents (Contrave, phentermine, Qsymia, Xenical, Saxenda, Wegovy, Zepbound)
  • Patient has no FDA labeled contraindications

Approval duration

BCBSIL FI & HIM: 12 months; All other plans: 3 months; Renewal: Qsymia ≥5% weight loss 12 months, <5% weight loss 3 months, all others 12 months