naltrexone/bupropion (Contrave®)

SELF ADMINISTRATION - ORAL

Indications for Prior Authorization:

  • Indicated as an adjunct to a reduced calorie diet and exercise for weight management

Patients must meet the following criteria for the indications above:

  • BMI > 30 kg/m2 AND
  • At least one comorbid condition confirmed by chart note documentation/prescription data:
    • Hypertension
    • Diabetes
    • Hyperlipidemia

The Following Conditions Do Not Meet the Criteria for Use as Established by the WHA P & T Committee:

  • All non-FDA approved indications
  • Patients who are pregnant or may become pregnant during therapy

Dosing:

  • Dose is titrated over 4 weeks. At 4 weeks patient should be taking 2 tablets twice a day
  • Higher doses are not approvable
  • Discontinue if weight loss >5% not achieved in 12 weeks

Approval:

  • Initial approval: 12 weeks
  • Renewal: 6 months
  • Renewal requires chart note documentation of reduction in patient weight

      

Last review date: December 1, 2014