Downloadable forms and documents to assist you with reimbursement processes for BELVIQ® and 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® >
This form is used to verify coverage for BELVIQ® or BELVIQ XR®.
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.
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®.
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.
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.
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®/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).
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 Eisai Inc.