benzphetamine — United Healthcare

Initial criteria

• Treatment is being requested for appetite suppression or weight loss OR Wegovy is being requested for risk reduction of major adverse cardiovascular events with established cardiovascular disease (i.e. prior myocardial infarction, ischemic or hemorrhagic stroke, or peripheral arterial disease) OR Zepbound is being requested for moderate to severe obstructive sleep apnea
• AND Patient is ≥ 12 years of age (for Qsymia, Saxenda, Wegovy and Xenical) OR Patient is > 16 years of age (for other appetite suppressants)
• AND Used as an adjunct to lifestyle modification (e.g., dietary or caloric restriction, exercise, behavioral support, community-based program)
• AND BMI ≥ 30 kg/m2 or for pediatric patients BMI > 95th percentile OR BMI ≥ 27 kg/m2 AND Patient has a weight-related comorbidity (e.g., dyslipidemia, hypertension, type 2 diabetes, sleep apnea)

Reauthorization criteria

• Weight loss of ≥ 3% of baseline body weight for Qsymia OR Weight loss of ≥ 4% of baseline body weight for Saxenda OR Weight loss of ≥ 5% of baseline body weight for all other appetite suppressants
• AND Continuation of lifestyle modification

Approval duration

Initial: benzphetamine, diethylpropion, phendimetrazine, phentermine 3 months; Contrave, Qsymia, Saxenda 4 months; Wegovy 5 months; Xenical, Zepbound 6 months. Reauth: Contrave, Qsymia, Saxenda, Wegovy, Xenical, Zepbound 12 months; benzphetamine, diethylpropion, phentermine, phendimetrazine 6 months.