Contrave — Highmark
chronic weight management in adults (Contrave, Qsymia) or adolescents (Xenical)
Initial criteria
- age ≥ 18 years for Contrave or Qsymia OR age ≥ 12 years for Xenical
- using requested product for chronic weight management (ICD-10: E66.0, E66.3)
- prescriber attests baseline height, weight, and BMI
- baseline BMI ≥ 30 kg/m2 OR BMI ≥ 27 kg/m2 with a weight-related comorbidity (e.g., hypertension, cardiovascular disease, dyslipidemia, obstructive sleep apnea)
- prescriber attests product will be used with lifestyle modification program (reduced calorie diet and increased physical activity)
- prescriber attests active participation ≥ 3 months prior to initiation in lifestyle modification program
Reauthorization criteria
- age ≥ 18 years for Contrave or Qsymia OR age ≥ 12 years for Xenical
- using requested product for chronic weight management (ICD-10: E66.0, E66.3)
- prescriber attests baseline and current height, weight, and BMI
- meets baseline BMI criteria (≥ 30 kg/m2 OR ≥ 27 kg/m2 with comorbidity)
- prescriber attests ongoing use with lifestyle modification program (reduced calorie diet and increased physical activity)
- member has experienced ≥ 5% weight loss from baseline for continuation
- member has maintained ≥ 5% weight loss from baseline for maintenance