Qsymia — Highmark
chronic weight management in adolescents or adults who initiated Qsymia as adolescents
Initial criteria
- age ≥ 12 years
- using Qsymia for chronic weight management (ICD-10: E66.0)
- prescriber attests baseline age, height, weight, and BMI
- baseline BMI ≥ 95th percentile standardized for age and sex
- prescriber attests use with lifestyle modification program (reduced calorie diet and increased physical activity)
- prescriber attests active participation ≥ 3 months prior to initiation in lifestyle modification program
Reauthorization criteria
- age ≥ 12 years
- using Qsymia for chronic weight management (ICD-10: E66.0)
- prescriber attests baseline and current age, height, weight, and BMI
- baseline BMI ≥ 95th percentile standardized for age and sex
- prescriber attests ongoing use with lifestyle modification program (reduced calorie diet and increased physical activity)
- member has experienced ≥ 5% weight loss from baseline AND maintained ≥ 5% weight loss