Qsymia — Medical Mutual

Weight Loss, Adult

Initial criteria

Patient is age ≥ 18 years; AND
Patient meets one of the following: (a) At baseline, the patient had a BMI ≥ 32 kg/m2; OR (b) At baseline, the patient had a BMI ≥ 27 kg/m2 and at least TWO of the following weight-related comorbidities: hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea (OSA), cardiovascular disease (CVD), knee osteoarthritis, asthma, chronic obstructive pulmonary disease (COPD), non-alcoholic steatohepatitis (NASH)/non-alcoholic fatty liver disease (NAFLD), polycystic ovarian syndrome (PCOS), or coronary artery disease (CAD); AND
Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months; AND
Qsymia will be used concomitantly with a behavioral modification program and a reduced calorie diet; AND
The prescriber does not specialize or practice primarily in anesthesiology, dentistry, emergency medicine, nuclear medicine, ophthalmology, pathology, or radiology.

Patient is age ≥ 18 years; AND
Patient meets one of the following at baseline: (a) BMI ≥ 32 kg/m2; OR (b) BMI ≥ 27 kg/m2 and at least TWO of specified weight-related comorbidities; AND
Qsymia will be used concomitantly with a behavioral modification program and a reduced calorie diet; AND
Patient has lost ≥ 5% of baseline body weight; AND
The prescriber does not specialize or practice primarily in anesthesiology, dentistry, emergency medicine, nuclear medicine, ophthalmology, pathology, or radiology.

initial 6 months, reauth 1 year