CONTRAVE (bupropion/naltrexone) diethylpropion (TENUATE, TENUATE DOSPAN), phendimetrazine (BONTRIL, BONTRIL PDM), phentermine (FASTIN, ADIPEX-P), QSYMIA (phentermine/topiramate), REGIMEX (benzphetamine), SUPRENZA ODT (phentermine), XENICAL (orlistat)

Diagnosis Considered for Coverage: • Obesity management (aka weight loss)

Coverage Criteria:

For generics & brand-name without generic equivalent AND diagnosis of adult obesity Initial Authorization • One of the following: a. Current BMI ≥ 40 kg/m2 or b. BMI 35-39 kg/m2 and patient has one of the following conditions: hypertension, diabetes, coronary artery disease, dyslipidemia, stroke, osteoarthritis requiring surgery, or patient has sleep apnea currently being treated with CPAP, or c. Both of the following: i. Current BMI of > 30 kg/m2 OR 27 kg/m2 in the presence of one of the following conditions: hypertension, diabetes, coronary artery disease, dyslipidemia, stroke, osteoarthritis requiring surgery, or patient has sleep apnea currently being treated with CPAP, and ii. Patient with diagnosis of mental health or substance use disorder, and • Patient had been evaluated by a physician to rule out other underlying endocrine causes of obesity, and • Patient meets FDA-approved age for use, and Diethylpropion 16 years of age or older Phendimetrazine, phentermine 17 years of age or older Contrave ER, Qysmia 18 years of age or older Xenical 12 years of age or older

• Patient has not undergone bariatric surgery within the previous 12 months, and • Not being used in combination with another weight loss agent, and • Patient has undergone at least 6 months of combination therapy consisting of both diet and exercise, and • Dose does not exceed FDA label maximum

Coverage Duration: All agents (except Contrave ER, Qsymia): 3 months Contrave ER: 16 weeks (12 weeks after starting maintenance dose) Qsymia: 7 months

Additional note to provider: For reauthorization, please provide the patient’s current weight to assess ongoing weight loss drug therapy.

1st reauthorization • Patient demonstrates at least 5% weight loss from baseline and weight is not within 10% ideal body weight (IBW), and • Not being used in combination with another weight loss agent, and • Dose does not exceed FDA label maximum.

Coverage Duration: 6 months

Subsequent reauthorization • Patient maintains at least 5% weight loss from baseline and weight is not within 10% ideal body weight (IBW), and • Not being used in combination with another weight loss agent, and • Dose does not exceed FDA label maximum.

Coverage Duration: 6 months

For brand-name with generic equivalent • Meets above coverage criteria for generic, and • Patient is allergic or experienced intolerable side effect to the generic formulation that is not also expected with the brand name Coverage Duration: See above Effective: 09/01/2021