Qsymia — Medical Mutual

Initial criteria

• Patient is age ≥ 12 years and < 18 years; AND
• Patient currently has a BMI of ≥ 95th percentile for age and sex; AND
• Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months; AND
• Patient is currently engaged in behavioral modification and on a reduced calorie diet; AND
• The prescriber does not specialize or practice primarily in anesthesiology, dentistry, emergency medicine, nuclear medicine, ophthalmology, pathology, or radiology.

Reauthorization criteria

• Patient is age ≥ 12 years and < 18 years; AND
• Patient had an initial BMI of ≥ 95th percentile for age and sex; AND
• Patient is currently engaged in behavioral modification and on a reduced calorie diet; AND
• Patient has had a reduction in BMI of ≥ 5% from baseline; AND
• The prescriber does not specialize or practice primarily in anesthesiology, dentistry, emergency medicine, nuclear medicine, ophthalmology, pathology, or radiology.

Approval duration

initial 6 months, reauth 1 year