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Qsymia (phentermine and topiramate extended-release) — CareFirst (Caremark)

Reduction in excess body weight and maintenance of weight reduction long term in adults and pediatric patients aged ≥12 years with obesity

Initial criteria

  • The drug will be used with a reduced-calorie diet AND increased physical activity to reduce excess body weight or maintain weight reduction long term
  • The patient has participated in a comprehensive weight management program that encourages behavioral modification, reduced-calorie diet, AND increased physical activity with continuing follow-up for at least 6 months prior to using drug therapy
  • If patient age ≥18 years: baseline BMI ≥30 kg/m2 OR baseline BMI ≥27 kg/m2 with at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia); documentation required
  • If patient age 12–17 years: baseline BMI in the 95th percentile or greater standardized for age and sex; documentation required

Reauthorization criteria

  • The drug will be used with a reduced-calorie diet AND increased physical activity to reduce excess body weight or maintain weight reduction long term
  • If patient age ≥18 years: ONE of the following is met:
  • • Completed ≥12 weeks of Qsymia 15 mg/92 mg therapy AND lost ≥5% of baseline body weight OR maintained initial 5% weight loss; documentation required
  • • Completed ≥12 weeks of Qsymia 7.5 mg/46 mg therapy AND lost ≥3% of baseline body weight OR maintained initial 3% weight loss; documentation required
  • • Dose increased to Qsymia 11.25 mg/69 mg AND will follow recommended dose escalation schedule; documentation required
  • If patient age 12–17 years: ONE of the following is met:
  • • Completed ≥12 weeks of Qsymia 15 mg/92 mg therapy AND experienced ≥5% reduction in baseline BMI OR maintained initial 5% BMI reduction; documentation required
  • • Completed ≥12 weeks of Qsymia 7.5 mg/46 mg therapy AND experienced ≥3% reduction in baseline BMI OR maintained initial 3% BMI reduction; documentation required
  • • Dose increased to Qsymia 11.25 mg/69 mg AND will follow recommended dose escalation schedule; documentation required

Approval duration

Initial: 3 months; Continuation: 12 months