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.
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.
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 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.
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.
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 Eisai Inc.