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Documents & Resources

Downloadable forms and documents to assist you with reimbursement processes for BELVIQ® and BELVIQ XR®.


RESOURCES

Provider Insurance Verification Portal for BELVIQ® or BELVIQ XR®

The online resource is for providers to research and understand their patients‘ insurance coverage for BELVIQ® or BELVIQ XR®.

Provider Insurance Verification Portal for BELVIQ® and BELVIQ XR® >

DOWNLOADABLE FORMS

BELVIQ® or BELVIQ XR® Insurance Verification Form

This form is used to verify coverage for BELVIQ® or BELVIQ XR®.

Rx Outreach Enrollment Application for BELVIQ®

This application is used to determine whether your patient may be eligible for the Rx Outreach Medication Program for BELVIQ®. This form has been annotated to include specific information as it relates to BELVIQ®. BELVIQ XR® is not available through the Patient Assistance Program at this time.


LETTERS

Sample Letter for Prior Authorization Request for BELVIQ® or BELVIQ XR®

The Sample Letter for Prior Authorization is a template of a letter that can be submitted to a payor to request coverage based on the need of a patient to use BELVIQ® or BELVIQ XR®.


Sample Letter of Appeal from HCP for BELVIQ® or BELVIQ XR®

The sample appeal letter is a template of a letter that can be submitted by the Healthcare Provider to appeal for coverage of BELVIQ® or BELVIQ XR® with a payor.


Sample Letter of Appeal from Patient for BELVIQ® or BELVIQ XR®

The sample appeal letter is a template of a letter that can be submitted by the patient to appeal for coverage of BELVIQ® or BELVIQ XR® with a payor.  In support of the letter of appeal, an appeal letter from the patient’s healthcare provider should also be submitted. A sample letter template is provided in the same document following the Sample Letter of Appeal from the patient.  


Was Your Patient Denied Coverage for BELVIQ® or BELVIQ XR®?

Find alternatives for requesting non-formulary coverage determination.

Physician Resources and Support

Get access to pivotal trial papers, news, and more

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.

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Indication

BELVIQ®/BELVIQ XR® 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 30 kg/m2 or greater (obese), or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, dyslipidemia, type 2 diabetes).

Limitations of Use

  • The safety and efficacy of coadministration of BELVIQ/BELVIQ XR with other products intended for weight loss, including prescription drugs (e.g., phentermine), over-the-counter drugs, and herbal preparations, have not been established.
  • The effect of BELVIQ/BELVIQ XR on cardiovascular morbidity and mortality has not been established.

Important Safety Information

Contraindications

  • Pregnancy: BELVIQ/BELVIQ XR should not be taken during pregnancy or by women who are planning to become pregnant.
  • Hypersensitivity: Patients with prior hypersensitivity reactions to lorcaserin or to any of the product components should not take BELVIQ/BELVIQ XR. Hypersensitivity reactions have been reported.

Warnings and Precautions

  • Serotonin Syndrome or Neuroleptic Malignant Syndrome (NMS)- like reactions: BELVIQ/BELVIQ XR is a serotonergic drug. The development of potentially life-threatening serotonin syndrome or Neuroleptic Malignant Syndrome (NMS)-like reactions have been reported during use of serotonergic drugs, including, but not limited to, selective serotonin-norepinephrine reuptake inhibitors, and selective serotonin reuptake inhibitors, tricyclic antidepressants, bupropion, triptans, dietary supplements such as St. John's Wort and tryptophan, drugs that impair metabolism of serotonin (including monoamine oxidase inhibitors), dextromethorphan, lithium, tramadol, antipsychotics or other dopamine antagonists, particularly when used in combination. Patients should be monitored for the emergence of serotonin syndrome symptoms or NMS-like reactions, including agitation, hallucinations, coma, tachycardia, labile blood pressure, hyperthermia, hyperreflexia, incoordination, nausea, vomiting, diarrhea, and muscle rigidity. Treatment with BELVIQ/BELVIQ XR and any concomitant serotonergic or antidopaminergic agents should be discontinued immediately if the above events occur and supportive symptomatic treatment should be initiated.
  • Valvular heart disease: Patients should not take BELVIQ/BELVIQ XR in combination with potent 5-HT2B receptor agonists that have been associated with regurgitant valvular heart disease (e.g., cabergoline). In clinical trials, 2.4% of patients taking BELVIQ and 2.0% of patients taking placebo developed valvular regurgitation: none of these patients were symptomatic. BELVIQ/BELVIQ XR should be used with caution in patients with congestive heart failure (CHF). Patients who develop signs and symptoms of valvular heart disease, including dyspnea, dependent edema, CHF, or a new cardiac murmur, should be evaluated and discontinuation of BELVIQ/BELVIQ XR should be considered.
  • Cognitive impairment: Impairment in attention, memory, somnolence, confusion, and fatigue have been reported in patients taking BELVIQ. Patients should not drive a car or operate heavy machinery until they know how BELVIQ/BELVIQ XR affects them.
  • Psychiatric disorders: The recommended daily dose should not be exceeded, as higher doses may cause euphoria, hallucination, and dissociation. Monitor patients for the development or worsening of depression, suicidal thoughts or behaviors, and/or any changes in mood. Discontinue BELVIQ/BELVIQ XR in patients who develop suicidal thoughts or behaviors.
  • Hypoglycemia: Weight loss may increase the risk of hypoglycemia in patients with type 2 diabetes mellitus who are being treated with antidiabetic medications, so measurement of blood sugar levels before and during treatment with BELVIQ/BELVIQ XR is recommended. Decreases in doses of antidiabetic medications or changes in medication regimen should be considered.
  • Priapism: Men who experience priapism should immediately discontinue BELVIQ/BELVIQ XR and seek emergency medical attention. BELVIQ/BELVIQ XR should be used with caution with erectile dysfunction medications. BELVIQ/BELVIQ XR should be used with caution in men who have conditions that might predispose them to priapism (e.g., sickle cell anemia, multiple myeloma, or leukemia), or in men with anatomical deformation of the penis (e.g., angulation, cavernosal fibrosis, or Peyronie's disease).
  • Heart rate decreases: Because BELVIQ/BELVIQ XR may cause a slow heartbeat, it should be used with caution in patients with a history of bradycardia or heart block greater than first degree.
  • Monitoring Considerations: Consider monitoring for CBC changes, signs and symptoms of prolactin excess, and pulmonary hypertension.

Most Common Adverse Reactions for BELVIQ®

  • In patients without diabetes: headache (17%), dizziness (9%), fatigue (7%), nausea (8%), dry mouth (5%), and constipation (6%).
  • In patients with diabetes: hypoglycemia (29%), headache (15%), back pain (12%), cough (8%), and fatigue (7%).

Most Common Adverse Reactions for BELVIQ XR®

  • Common side effects in patients on BELVIQ XR were similar to those seen in patients on BELVIQ.

Nursing Mothers

  • BELVIQ/BELVIQ XR should not be taken by women who are nursing.
 
BELVIQ®/BELVIQ XR® is a federally controlled substance (CIV) because they may be abused or lead to dependence.
 
For more information about BELVIQ®/BELVIQ XR® see full Prescribing Information

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® and BELVIQ XR® are registered trademarks of Arena Pharmaceuticals GmbH.

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