Subject: Antiobesity Agents

Policy:

Class Edit Summary
NOTE:  Drugs 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 plans), and are not, therefore, included on Aetna's Formulary. 

1. Medical Exception Criteria




 The following antiobesity agents are included in this clinical policy bulletin.

Generic name	Brand name
phendimetrazine	Bontril®, Melfiat-105®, Prelu-2®
phentermine	Ionamin®, Phentride®, Fastin®, Adipex-P®, Obe-Nix®, Oby-Trim®, Pro-Fast®
diethylpropion	Tenuate®
benzphetamine	Didrex®
mazindol	Mazanor®, Sanorex®
sibutramine	Meridia®
orlistat	Xenical®






Drugs used for the sole purpose of weight reduction are generally not a covered benefit under most Aetna drug benefits plans. If covered as a benefit, Aetna considers Antiobesity Agents to be medically necessary for those members who meet the following criteria:

A.  A documented:

• Body mass index > 30 kg/m2
  OR
• Body mass index > 27 kg/m2 with one or more of the following obesity related risk factors considered serious enough to warrant pharmacotherapy:
  a. Hypertension (systolic blood pressure > 140 mm Hg or diastolic blood pressure > 90 mm Hg on more than one occasion)
  b. Dyslipidemia
  1. LDL cholesterol > 160 mg/dL, or
  2. HDL cholesterol < 35 mg/dL, or
  3. Triglycerides > 400 mg/dL
  c. Coronary heart disease
  d. Type 2 diabetes mellitus
  e. Obstructive sleep apnea.
  

AND

B.   Member is NOT receiving two antiobesity agents at the same time.

Place of Service:

Outpatient

The above policy is based on the following references:

1. Drug Facts and Comparisons on-line. (www.drugfacts.com), Wolters Kluwer Health, St. Louis, MO. 2006.
2. USP DI® Drug Information For The Health Care Professional - 26th Ed. (online from www.statref.com) Thomson Micromedex, Greenwood Village, CO. 2006.
3. AHFS Drug Information® with AHFSfirstReleases®. (online from www.statref.com), American Society Of Health-System Pharmacists®, Bethesda, MD. 2006.
4. DRUGDEX^® System: Klasco RK (Ed):DRUGDEX^® System. Online edition. Thomson Micromedex, Greenwood Village, CO.
5. PDR^® Electronic Library, Thomson Micromedex, Greenwood Village, Colorado (Edition expires 2006).
6. Aetna Medical Clinical Policy Bulletin (CPB) #157: Obesity: Surgical Treatment; revised September 8, 2006. http://www.aetna.com/cpb/data/CPBA0157.html.
7. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. National Heart, Lung, and Blood Institute/National Institute of Diabetes and Digestive and Kidney Diseases. 1998 Jun. 228 pages.
8. Haller C, Schwartz JB. Pharmacologic agents for weight reduction. J Gend Specif Med. 2002;5(5):16-21.
9. Shepherd TM. Effective management of obesity. J Fam Pract. 2003;52(1):34-42.
10. Institute for Clinical Systems Improvement (ICSI). Pharmacological approaches to weight loss in adults. Bloomington, MN: ICSI; 2003.
11. Asp N G, Bjorntorp P, Britton M, et al. Obesity - problems and interventions. Stockholm, Sweden: Swedish Council on Technology Assessment in Health Care (SBU); 2002.
12. O'Meara S, Riemsma R, Shirran L, et al. A rapid and systematic review of the clinical effectiveness and cost-effectiveness of orlistat in the management of obesity. Health Technol Assess. 2001;5(18).
13. NHS Centre for Reviews and Dissemination (CRD). The prevention and treatment of childhood obesity. York, UK: CRD; 2002.
14. American Gastroenterological Association medical position statement on obesity. Gastroenterology. 2002;123(3):879-881.
15. Aetna Medical Clinical Policy Bulletin (CPB) #39: Weight Reduction Medications and Programs; revised August 4, 2006. http://www.aetna.com/cpb/data/CPBA0039.html.
16.  Revised dietary guidelines to help Americans live healthier lives. FDA Consum. 2005 Mar-Apr;39(2):18-9.
17. Arterburn D, DeLaet D, Flum D. Obesity. Clin Evid. 2005;(13):707-25.
18. Norris SL, Zhang X, Avenell A, Gregg E, Schmid CH, Lau J. Pharmacotherapy for weight loss in adults with type 2 diabetes mellitus. Cochrane Database Syst Rev. 2005 Jan 25;(1):CD004096.
19. Weight-control practices among U.S. adults, 2001-2002. Am J Prev Med. 2006;31(1):18-24.
20. Finer N, Ryan DH, Renz CL, Hewkin AC. Prediction of response to sibutramine therapy in obese non-diabetic and diabetic patients. Diabetes Obes Metab. 2006;8(2):206-13.

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 01, 2007