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Pharmacy Clinical Policy Bulletins
Aetna Non-Medicare Prescription Drug Plan
Subject: Antiobesity Agents

Status Drug PR PR-QL PR-AL ST M EX‡
P phentermine X        
P benzphetamine X        
P diethylpropion X        
P phendimetrazine X        
P Belviq®  (lorcaserin) X        
P Qsymia™  (phentermine and topiramate extended release) X        
NP Adipex®  (phentermine) X        
NP Bontril®  (phendimetrazine) X        
NP Contrave®  (naltrexone hcl-bupropion hcl sr) X        
NP Didrex®  (benzphetamine) X        
NP Regimex ®  (benzphetamine) X        
NP Suprenza™  (phentermine hcl orally disintegrating) X        
NP Xenical®  (orlistat) X        
Note: Medications used for the sole purpose of weight reduction are generally not a covered benefit under most Aetna drug benefits plans.  Coverage may be provided under the member's Aetna medical benefits plan.  Please see plan benefit descriptions for further detail.


Policy:

The above medications are excluded from coverage on Aetna's standard formulary.  If the plan elects coverage, these medications may be subject to coverage for medical necessity only.  Please see plan benefit descrition for further coverage details.   

  1. Precertification Criteria
  2. Under some plans, including those that use an open or closed formulary, Adipex, Belviq, benzphetamine, Bontril, Contrave, Didrex, diethylpropion, phendimetrazine, phentermine, Qsymia, Regimex, Suprenza, and Xenical may be subject to precertification for medical necessity.  Aetna considers these medications to be medically necessary for those members who meet all of the following medically necessary criteria:

    For Adipex, Belviq, benzphetamine, Bontril, Contrave, Didrex, diethylpropion, phendimetrazine, phentermine, Qsymia, Regimex, Suprenza, and Xenical

    For initial authorization:

    • A documented Body Mass Index (BMI) > 30 kg/ m2 OR
    • A documented BMI > 27 kg/ m2 with one or more of the following obesity related risk factors considered serious enough to warrant pharmacotherapy:
      • Hypertension (systolic blood pressure > 140 mm Hg or diastolic blood pressure > 90 mm Hg on more than one occasion)
      • Dyslipidemia
        • LDL cholesterol >/= 160 mg/ dL
        • HDL cholesterol < 35 mg/ dL
        • Triglycerides >/= 400 mg/ dL
      • Type 2 diabetes mellitus
      • Coronary heart disease
      • Obstructive sleep apnea

    AND

    • If female, member is not pregnant AND
    • Member is not receiving two antiobesity agents at the same time

    For Belviq and Qsymia

    For reauthorization at 12 weeks (auth one year):

    • Initial authorization criteria above has been met AND
      • Member has experienced a documented weight loss of at least 5% of baseline body weight (Belviq only) OR
      • Member has experienced a documented weight loss of at least 3% of baseline body weight (Qsymia only)

Place of Service:

Outpatient

The above policy is based on the following references:

1. DrugPoints® System ( www.statref.com) Thomson Micromedex, Greenwood Village, CO. Updated periodically.
2. AHFS Drug Information® with AHFSfirstReleases®. ( www.statref.com), American Society Of Health-System Pharmacists®, Bethesda, MD. Updated periodically.
3. DRUGDEX® System [Internet database]. Greenwood Village, Colo: Thomson Micromedex. Updated periodically.
4. Drug Facts and Comparisons on-line. (www.drugfacts.com), Wolters Kluwer Health, St. Louis, MO. Updated periodically.
5. PDR® Electronic Library™ [Internet database]. Greenwood Village, Colo: Thomson Micromedex. Updated periodically.
6. National Heart, Lung, and Blood Institute; Expert Panel on the Identification, Evaluation, and Treatment of Overweight in Adults. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: executive summary. Am J Clin Nutr. 1998;68(4):899-917.
7. Belviq® [package insert]. Woodcliff Lake, NJ: Eisai Inc.; August 2012
8. Qsymia® [package insert]. Winchester, KY: Vivus Inc.; September 2013

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

January 12, 2015
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