Qsymia (phentermine/topiramate extended-release) — Cigna

Weight Loss, Pediatric

Initial criteria

Adult: Patient is age ≥ 18 years; AND
Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months; AND
Patient meets ONE of the following (a or b): a) At baseline, BMI ≥ 30 kg/m2; OR b) BOTH [(1) and (2)]: (1) Baseline BMI ≥ 27 kg/m2; AND (2) Baseline or current ≥ 1 weight-related comorbidity as listed (hypertension, type 2 diabetes, etc.); AND
Medication will be used with behavioral modification and a reduced-calorie diet.
Pediatric: Patient is age ≥ 12 years and < 18 years; AND
Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months; AND
At baseline, BMI ≥ 95th percentile for age and sex; AND
Medication will be used with behavioral modification and a reduced-calorie diet.

Adult: Patient is age ≥ 18 years; AND
Patient meets ONE of the following (a or b): a) Baseline BMI ≥ 30 kg/m2; OR b) BOTH [(1) and (2)]: (1) Baseline BMI ≥ 27 kg/m2; AND (2) Baseline or current ≥ 1 listed comorbidity; AND
Patient has lost ≥ 5% of baseline body weight; AND
Medication will be used with behavioral modification and a reduced-calorie diet.
Pediatric: Patient is age ≥ 12 years and < 18 years; AND
At baseline, BMI ≥ 95th percentile for age and sex; AND
Patient has had a reduction in BMI of ≥ 5% from baseline; AND
Medication will be used with behavioral modification and a reduced-calorie diet.

initial 6 months; reauth 1 year