Coverage for BELVIQ® is primarily through a patient’s pharmacy benefit. Coverage and reimbursement may vary significantly by payor, plan and patient. Payors can base coverage decisions on formal policies or make decisions on a case-by-case basis.
Medicare, in its definition of a covered Part D drug, specifically addresses drugs or classes of drugs, or their medical uses, which may be excluded from coverage or otherwise restricted under section 1927(d)(2) of the Social Security Act. Agents when used for anorexia, weight loss, or weight gain (even if used for a non-cosmetic purpose i.e., morbid obesity) are excluded from coverage.1 It is therefore highly unlikely that any weight-loss product, including BELVIQ®, will be reimbursable through the standard Part D prescription drug plan.
However, in addition to the standard Part D prescription drug plan, Medicare offers enrollees prescription drug coverage through enhanced Part D plans that may allow for weight-loss product coverage.2
Enhanced alternative coverage includes both basic prescription drug coverage and supplemental benefits. Some Part D prescription drug plans may offer coverage for weight-loss drugs beyond the standard benefit. Enrollees may choose to pay extra to receive coverage under the optional supplemental benefit.
For more information on coverage for BELVIQ®, enrolled members will need to check their benefit plan descriptions for details. Providers can also contact the Eisai Assistance Program at 1-866-61-EISAI (1-866-613-4724) to research their patients’ benefits.
1. Centers for Medicare & Medicaid Services Website. Prescription Drug Benefit Manual, Chapter 6: Part D Drugs and Formulary Requirements, Information available at
Accessed March 17, 2016.
2. Centers for Medicare & Medicaid Services Website. Prescription Drug Benefit Manual, Chapter 5: Benefits and Beneficiary Protections, Information available at
Accessed March 17, 2016.
Medicaid is a government insurance program that covers low-income parents and children, people who are elderly, and people with disabilities. State Medicaid programs and the federal government share the costs of covering most medical expenses for Medicaid beneficiaries.
Weight-loss products are one of the classes of drugs that Medicaid programs may exclude from coverage or otherwise restrict under federal law.1 Coverage and reimbursement for BELVIQ® will vary from state to state, as each Medicaid program establishes its own eligibility standards and determines the type, amount, duration, and scope of services.
Reimbursement for BELVIQ® is expected to vary greatly from one state Medicaid program to another. State Medicaid programs are likely to apply coverage and utilization restrictions such as prior authorization or step therapy edits. Currently, less than half of all states offer coverage for weight-loss drugs. Additional payor review may be required to document the individual's weight loss, the patient's body mass index (BMI), or to verify the presence of risk factors/co-morbid conditions such as hypertension, dyslipidemia, and diabetes.
For more information on Medicaid reimbursement for BELVIQ® contact your Medicaid program. Providers can also contact the Eisai Assistance Program at 1-866-61-EISAI (1-866-613-4724) to research your patients’ benefits.
1. Social Security Law. Payment for covered outpatient drugs. Available at http://www.ssa.gov/OP_Home/ssact/title19/1927.htm. Accessed March 17, 2016.
Coverage for obesity related drugs is highly variable amongst plans offered by commercial payors. Payors generally implement "medical necessity" criteria for treatment of obesity or weight control. Weight reduction medications may be considered experimental and investigational when criteria are not met. For example, plans may reject a claim received that lists obesity as the sole diagnosis code.
Most third-party payors, including Health Maintenance Organization (HMO) plans, managed care organizations, indemnity plans, and others, may initially deny coverage for BELVIQ® or limit coverage to patients suffering with co-morbid conditions such as diabetes. However, specific coverage requirements and restrictions will vary based on plan type. While some payors have established formal published policies, the lack of a published policy from a particular payor does not mean that BELVIQ® is not covered by that payor.
Some plans only cover weight-loss drugs included on this list; others charge a higher copayment for drugs not on the formulary. Formularies are often organized into tiers. If a plan's pharmacy benefit involves tiers, members typically pay the smallest copayments for drugs in the lowest tier and the highest copayments for drugs in the highest tier. Some commercial plans may apply coverage and utilization restrictions such as prior authorization or quantity limit edits to BELVIQ®.
Coverage of weight-loss drugs is determined by the member's pharmacy benefit. Providers or patients should contact the health plan directly to determine whether BELVIQ® is included on the formulary. If BELVIQ® is not covered by the plan, an exception may be requested by the prescriber. Determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the member's contract, including medical necessity requirements.
If you need additional assistance obtaining a payor's specific requirements for requesting coverage for BELVIQ®, please call The Eisai Assistance Program at 1-866-61-EISAI.
Health plans may grant various types of exceptions to members. Members may receive coverage for BELVIQ® even if it is not on the formulary, health plans may waive coverage restrictions or limits and make an exception to cover the drug.
When requesting an exception, a statement from their prescriber must be submitted via fax or mail. The statement must explain the medical reasons for requesting an exception. Once a request is submitted, a decision is generally made within 72 hours of receiving the prescriber's supporting statement. Members can request an expedited (fast) exception if the prescriber believes that a patient's health could be seriously harmed by waiting up to 72 hours for a decision.
If the request is expedited and granted, the health plan usually gives a decision no later than 24 hours after receiving prescriber's supporting statement.
If the decision is not in member's favor, the health plan will send a written statement with explanation and how to appeal the decision.
To download forms that may be used to request patient coverage when BELVIQ® is not on the formulary, please click here. Please note that some payors may not accept requests for coverage that are submitted on forms that have not been approved by their specific plan.
If you need additional assistance obtaining a payor's specific requirements for requesting coverage for BELVIQ®, please call the Eisai Assistance Program at 1-866-61-EISAI or click here to obtain an Insurance Verification Form. Once completed, please fax it to the Eisai Assistance Program. A representative will initiate research into the specific requirements of your patient's insurance to obtain coverage.
An appeal is a request to change a previous adverse decision made by a health plan. A representative/prescriber or patient may appeal the adverse decision related to coverage. The prescriber will need to provide a reason why he/she believes the adverse coverage decision was incorrect and what the expected outcome should be. Along with the request form, supporting documentation may include previous medical necessity-related denials, the patient's medical records, and documentation from the healthcare professional or facility.
For more information on commercial payor-specific coverage of BELVIQ® providers can contact the member services department at their patients’ health plan. Providers can also contact the Eisai Assistance Program at 1-866-61-EISAI (1-866-613-4724) to research your patients’ benefits.
Eisai cannot guarantee payment of any claim. Coding, coverage, and reimbursement may vary significantly by payor, plan, patient, and setting of care. Actual coverage and reimbursement decisions are made by individual payors following the receipt of claims. For additional information, customers should consult with their payors for all relevant coding, reimbursement, and coverage requirements. It is the sole responsibility of the provider to select the proper code and ensure the accuracy of all claims used in seeking reimbursement. All services must be medically appropriate and properly supported in the patient medical record.
BELVIQ® is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of:
This information is intended for use by healthcare professionals in the United States only. Eisai Inc. recognizes the Internet is a global communications medium; however, laws, regulatory requirements, and medical practices for pharmaceutical products vary from country to country. The Prescribing Information included here is not appropriate for use outside the United States. This site contains information about products that may have different product labeling in different countries. This site is published by Eisai Inc.
BELVIQ® is a registered trademark of Arena Pharmaceuticals GmbH used by Eisai.