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Contrave — Blue Cross Blue Shield of Kansas

weight management

Initial criteria

  • 1. ONE of the following:
  • A. The patient is an adult (age ≥ 18 years) AND ALL of the following:
  • 1. ONE of the following:
  • A. BMI ≥ 30 kg/m² OR BMI ≥ 25 kg/m² if South Asian, Southeast Asian, or East Asian descent OR
  • B. BMI ≥ 27 kg/m² with at least one weight-related comorbidity/risk factor/complication (e.g., diabetes, dyslipidemia, coronary artery disease) AND
  • 2. Patient has been on a weight loss regimen of low-calorie diet, increased physical activity, and behavioral modifications for ≥ 6 months prior to initiation AND
  • 3. Patient is currently on and will continue such a regimen OR
  • B. The patient is pediatric (age 12–17 years) AND ALL of the following:
  • 1. ONE of the following:
  • A. BMI ≥ 95th percentile for age/gender OR
  • B. BMI ≥ 30 kg/m² OR
  • C. BMI ≥ 85th percentile for age/gender AND at least one weight-related comorbidity/risk factor/complication (e.g., hypertension, dyslipidemia, type 2 diabetes, obstructive sleep apnea) AND
  • 2. Patient has been on weight loss regimen (diet, activity, behavioral modification) ≥ 6 months prior to initiation AND
  • 3. Patient is currently on and will continue regimen
  • 2. If the patient has an FDA labeled indication: ONE of the following:
  • A. Patient age is within FDA labeling for requested agent OR
  • B. There is support for use at this age for the requested indication
  • 3. ONE of the following:
  • A. Patient has NOT tried a targeted weight loss agent (benzphetamine, Contrave, diethylpropion, phendimetrazine, phentermine, Qsymia, Xenical/Orlistat) in past 12 months OR
  • B. BOTH of the following:
  • 1. Patient has tried a targeted agent in the past 12 months AND
  • 2. Prescriber anticipates success with repeating therapy
  • 4. ONE of the following:
  • A. Requested agent is benzphetamine, diethylpropion, phendimetrazine, or phentermine OR
  • B. Requested agent is Qsymia AND ONE of the following:
  • 1. Requested dose is 3.75 mg/23 mg OR
  • 2. Patient currently treated with Qsymia, requested dose > 3.75/23 mg AND ONE of the following:
  • A. Pediatric patient has ≥ 5% reduction of baseline BMI OR
  • B. Adult patient has maintained ≥ 5% weight loss from baseline OR
  • C. Received < 14 weeks therapy OR
  • D. Dose being titrated upward OR
  • E. Received < 12 weeks on highest strength (15 mg/92 mg) OR
  • 3. There is support for therapy at the requested dose
  • C. Requested agent is Contrave AND ONE of the following:
  • 1. Patient newly starting therapy OR
  • 2. Currently treated, received < 16 weeks therapy OR
  • 3. Achieved and maintained ≥ 5% weight loss from baseline
  • D. Requested agent is Xenical (Orlistat) AND ONE of the following:
  • 1. If age 12–16 years AND ONE of:
  • A. Newly starting therapy OR
  • B. Currently treated < 12 weeks OR
  • C. Achieved ≥ 4% weight loss from baseline OR
  • 2. If age ≥ 17 years AND ONE of:
  • A. Newly starting therapy OR
  • B. Currently treated < 12 weeks OR
  • C. Achieved ≥ 5% weight loss from baseline
  • 5. The patient will NOT use the requested agent in combination with another weight loss agent (e.g., Contrave, phentermine, Qsymia, Xenical, Saxenda, Wegovy, Zepbound)
  • 6. Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

3 months