Phentermine and topiramate (Qsymia)

SELF ADMINISTRATION - ORAL

Indications for Prior Authorization

  • Indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management.

Patients must meet the following criteria for the indications above:

  • BMI > 30 kg/m2 AND
  • At least one comorbid condition confirmed by chart note documentation/prescription data:
    • Hypertension
    • Diabetes
    • Hyperlipidemia

The following conditions do not meet the criteria for use as established by the WHA P&T Committee:

  • All non-FDA approved indications
  • Patients who are pregnant or may become pregnant during therapy

Dosing:

  • Initially 3.75 mg/23 mg once daily in the morning for 14 days, then increased to 7.5 mg/46 mg  once daily in the morning
  • Maximum dose 15 mg/92 mg once daily
  • Discontinue if weight loss >5% not achieved in 12 weeks
  • Discontinue 15 mg/92 mg dose gradually to prevent possible seizure

Approval:

  • Initial approval: 12 weeks
  • Renewal: 6 months
  • Renewal requires chart note documentation of reduction in patient weight