Is Qsymia Covered By Aetna?
Yes, under certain conditions.
Qsymia is a combination of phentermine and topiramate, FDA-approved for chronic weight management in adults with obesity or overweight with a weight-related comorbidity. Aetna may provide coverage for Qsymia if specific documentation and eligibility criteria are met.
Does Qsymia Require Prior Authorization?
Yes.
Aetna often requires:
- BMI of ≥30, or ≥27 with a comorbidity (e.g., hypertension, high cholesterol, type 2 diabetes)
- Documentation of past weight loss efforts (diet, exercise, behavioral therapy)
- Proposed dosage and plan of treatment
Are There Coverage Restrictions?
Yes.
Restrictions may include:
- Step therapy requirements (e.g., trial of lifestyle management first)
- Limits on duration or refill frequency
- Tier placement impacting cost-sharing
Is Qsymia Covered for Adolescents?
No.
Qsymia is currently only FDA-approved for adults, and Aetna does not typically offer pediatric coverage.
What Documentation Is Needed?
To maximize approval chances, include:
- BMI and diagnosis
- Comorbidity history and prior failed treatments
- Timeline of lifestyle intervention attempts
- Medical necessity letter from your provider
What If Coverage Is Denied?
Patients may appeal the denial with:
- A revised letter of medical necessity
- Updated clinical records
- Explanation of failed alternatives
Where to Get More Info
FAQ: Aetna and Qsymia Coverage
Does Aetna cover Qsymia for weight loss?
Yes, if the patient meets clinical criteria and documentation is provided.
Is prior authorization required?
Yes. Documentation should show BMI, failed weight loss attempts, and comorbidities.
Can Qsymia be used if other medications fail?
Yes. This may strengthen your case for approval when documented.
What are the advantages of Qsymia compared to injectables?
Qsymia is often more affordable and available in pill form.
What if Aetna denies Qsymia?
Appeal with your provider’s support and thorough medical documentation.
Related pages: Ozempic, Saxenda, Mounjaro, Zepbound, Contrave
Medical Disclaimer
This page is for informational purposes only and is not intended as medical advice. Coverage varies by Aetna plan and region. Always consult your healthcare provider and insurer for personalized guidance.