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Documents & Resources

Downloadable sample letters and resources to help you with insurance approval for BELVIQ® and BELVIQ XR®.

FORMS and LETTERS

Rx Outreach Enrollment Application for BELVIQ®

This application is used to determine whether you may be eligible for 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.


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

The sample appeal letter is a template of 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. 


Investigating Your Insurance Coverage

Find out what you can do if you receive a denial of coverage for BELVIQ® or BELVIQ XR®

Chronic Weight Management with BELVIQ® or BELVIQ XR®

Making a commitment to losing weight is a big step

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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What is BELVIQ®/BELVIQ XR®?

BELVIQ®/BELVIQ XR® is a FDA-approved prescription weight-loss medication that, when used with diet and exercise, can help some adults (Body Mass Index [BMI] ≥27 kg/m²) living with extra weight, with a weight-related medical problem, or adults living with obesity (BMI≥30 kg/m²), lose weight and keep it off.

It is not known if BELVIQ/BELVIQ XR when taken with other prescription, over-the-counter, or herbal weight-loss products is safe and effective. It is not known if BELVIQ/BELVIQ XR changes your risk of heart problems, stroke, or death due to heart problems or stroke.

Important Safety Information

  • Pregnancy:

    Do not take if you are pregnant or planning to become pregnant, as weight loss offers no benefit during pregnancy and BELVIQ/BELVIQ XR may harm your unborn baby.
  • Hypersensitivity reactions:

    Do not take if you are allergic to lorcaserin or any of the ingredients in BELVIQ/BELVIQ XR.
  • Serotonin Syndrome or Neuroleptic Malignant Syndrome (NMS)-like reactions:

    Before using, tell your Healthcare Provider about all the medicines you take, especially medicines that treat depression, migraines, mental problems, or the common cold. These medicines may cause serious or life-threatening side effects if taken with BELVIQ/BELVIQ XR. Call your Healthcare Provider right away if you experience agitation, hallucinations, confusion, or other changes in mental status; coordination problems; uncontrolled muscle spasms; muscle twitching; restlessness; racing or fast heartbeat; high or low blood pressure; sweating; fever; nausea; vomiting; diarrhea; or stiff muscles.
  • Valvular heart disease:

    Some people taking medicines like BELVIQ/BELVIQ XR have had heart valve problems. Call your Healthcare Provider right away if you experience trouble breathing; swelling of the arms, legs, ankles, or feet; dizziness, fatigue, or weakness that will not go away; or fast or irregular heartbeat. Before taking BELVIQ/BELVIQ XR, tell your Healthcare Provider if you have or have had heart problems.
  • Changes in attention or memory:

    BELVIQ/BELVIQ XR may slow your thinking. You should not drive a car or operate heavy equipment until you know how BELVIQ/BELVIQ XR affects you.
  • Mental problems:

    Taking too much BELVIQ/BELVIQ XR may cause hallucinations, a feeling of being high or in a very good mood, or feelings of standing outside your body.
  • Depression or thoughts of suicide:

    Call your Healthcare Provider right away if you notice any mental changes, especially sudden changes in your mood, behaviors, thoughts, or feelings, or if you have depression or thoughts of suicide.
  • Low blood sugar:

    Weight loss can cause low blood sugar in people taking medicines for type 2 diabetes, such as insulin or sulfonylureas. Blood sugar levels should be checked before and while taking BELVIQ/BELVIQ XR. Changes to diabetes medication may be needed if low blood sugar develops.
  • Painful erections:

    If you have an erection lasting more than 4 hours while on, stop taking BELVIQ/BELVIQ XR and call your Healthcare Provider or go to the nearest emergency room right away.
  • Slow heartbeat:

    BELVIQ/BELVIQ XR may cause your heart to beat slower.
  • Decreases in blood cell count:

    BELVIQ/BELVIQ XR may cause your red and white blood cell counts to decrease.
  • Increase in prolactin:

    BELVIQ/BELVIQ XR may increase the amount of a hormone called prolactin. Tell your Healthcare Provider if your breasts begin to make milk or a milky fluid, or if you are a male and your breasts increase in size.
  • Most common side effects of BELVIQ® or BELVIQ XR®:

    Headache, dizziness, fatigue, nausea, dry mouth, constipation, cough, low blood sugar (hypoglycemia) in patients with diabetes, and back pain.
  • Nursing:

    BELVIQ/BELVIQ XR should not be taken while breastfeeding.
  • Drug interactions:

    Before taking BELVIQ/BELVIQ XR, tell your Healthcare Provider if you take medicines for depression, migraines, or other medical conditions, such as: triptans; medicines used to treat mood, anxiety, psychotic or thought disorders, including tricyclics, lithium, selective serotonin reuptake inhibitors, selective serotonin-norepinephrine reuptake inhibitors, monoamine oxidase inhibitors, or antipsychotics; cabergoline; linezolid (an antibiotic); tramadol; dextromethorphan (an over-the-counter (OTC) common cold/cough medicine); OTC supplements such as tryptophan or St. John’s Wort; or erectile dysfunction medicines.

BELVIQ®/BELVIQ XR® is a federally controlled substance (CIV) because they may be abused or lead to drug dependence.

For more information about BELVIQ®/BELVIQ XR® talk to your Healthcare Provider and see the full Product Information.

You are encouraged to report negative side effects of prescription drugs to the FDA.

Visit www.fda.gov/medwatch or call 1-800-FDA-1088.

The information contained herein is provided for educational purposes only and is not intended to replace discussions with a healthcare professional. All decisions regarding patient care must be made with a healthcare professional, considering the unique characteristics of the patient.

This site is intended for residents of the United States only. Any products discussed herein may have different product labeling in different countries.

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