CurrentHealth NetPolicy CP CPA.326

Benzphetamine for weight management

Policy governs medical necessity and coverage criteria for benzphetamine as a short-term adjunct for weight loss in members meeting specified BMI and program participation criteria. Affects providers requesting authorization for benzphetamine under Health Net/Centene-affiliated plans.

Policy Summary

PayerHealth Net

PolicyBenzphetamine for weight management

Policy CodePolicy CP CPA.326

Change TypePeriodic annual reviewmaterial updates in 2Q2023 and 2Q2024

Effective DateJun 1, 2018

Next Review Date

Key ActionSubmit prior authorization with documentation proving BMI eligibility and at least 6 months active enrollment in a weight loss program including behavioral modification.

SourceLink

POLICY UPDATE CHANGES

2Q 2024 annual review: added requirement that members be actively enrolled in a weight loss program for at least 6 months and that the program include behavioral modification per ACC/AHA guidelines

2Q 2023 annual review: for patients age 17 years, added obesity defined as BMI ≥ 95th percentile for age and sex per AAP; added 25 mg tablet strength; removed a continued therapy criterion referencing BMI ≥ 25 kg/m2

2Q 2025 annual review: no significant changes; references reviewed and updated, Approval Date = 05.25

12 weeksmaximum approved treatment duration

150 mg/daymaximum daily dose

BMI >30 or >27+riskprimary BMI eligibility thresholds

6 months

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minimum program enrollment

25 mg, 50 mgtablet strengths available

Coverage Criteria for Benzphetamine

Continuation Therapy

Covered continuation when ALL of the following are met:

Continued therapy: 1) Member is currently receiving medication via the Centene benefit or has previously met initial approval criteria; 2) Member is responding positively to therapy as evidenced by weight loss from baseline; 3) Documentation that member is actively enrolled in a weight loss program that involves a reduced calorie diet, increased physical activity, and behavioral modification adjunct to therapy; 4) If request is for a dose increase, new dose does not exceed 150 mg per day; 5) Total treatment duration does not exceed 12 weeks.see node details

Approval duration: up to 12 weeks total

Notable criteria changes

Policy criteria updates noted in annual reviews

Initial therapy documentation: Member must be actively enrolled in a weight loss program that includes behavioral modification for at least 6 months.>= 6 months enrollment

Added in 2Q 2024 annual review; aligned with ACC/AHA guidance

Contraindications include pregnancy; symptomatic cardiovascular disease; moderate to severe hypertension; history of drug abuse; hyperthyroidism; glaucoma; concomitant use of or use within 14 days of monoamine oxidase (MAO) inhibitors; advanced arteriosclerosis; agitated states; concomitant use of central nervous system stimulants; and known hypersensitivity to sympathomimetic amines.

Coverage under this policy is subject to the terms, conditions, exclusions, and limitations of the member's coverage documents and applicable law; the policy itself does not guarantee payment. The Health Plan retains the right to change, amend, or withdraw this clinical policy and to apply plan-level administrative policies and procedures when making coverage determinations.

Requests for non‑FDA approved indications not addressed in this policy are not authorized unless sufficient documentation of efficacy and safety is provided in accordance with the Health Plan's off‑label use policy CP.CPA.09 or other applicable evidence of coverage documents.

This clinical policy is intended to serve as the Health Plan's medical necessity guide. Services or requests that do not meet the plan criteria and the requirements of the member's coverage documents may be deemed not medically necessary and may be denied in plan adjudication.

Key Clinical Thresholds and Dosing

inv-08: BMI thresholds — Adults and adolescent rule summary

Adults — primary eligibilityBMI > 30 OR BMI > 27 with at least one obesity‑related comorbidity (e.g., coronary artery/heart disease, hypertension, dyslipidemia, diabetes, elevated waist circumference) or other obesity‑related medical condition

Adolescent (age 17) — eligibilityBMI ≥ 95th percentile for age and sex (per AAP pediatric BMI‑for‑age percentiles)

Approval duration (initial)12 weeks

Reference guidanceSee Initial Approval Criteria for required documentation of weight loss program participation and behavioral modification

inv-09: Dose limit — Maximum daily dose

Maximum daily doseDo not exceed 150 mg per day

Prior Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for benzphetamine. Providers must obtain approval before initiating therapy per Health Net prior authorization processes; coverage is contingent on meeting the medical necessity criteria in this policy.

Approval duration: 12 weeks
Dose limit: ≤ 150 mg per day

Prior Authorization

Prior Authorization Guidance

This clinical policy serves as the plan's medical necessity guidance for prior authorization decisions. Authorization requests will be evaluated against the criteria in this policy; if the request or submitted documentation does not demonstrate that the member meets the policy criteria, the prior authorization may be denied.

Documentation Required

Clinical Background

Benzphetamine is a sympathomimetic amine with pharmacologic activity similar to the amphetamines and is FDA‑indicated as a short‑term adjunct to caloric restriction in the management of exogenous obesity. The policy notes formulation changes and strength additions over time and documents annual reviews through 2Q 2025.

Definitions and Measurement

inv-21: BMI — formula and usage notes

BMI formulaBMI = 703 x [weight (lbs) / height (inches)^2]

UseApply adult BMI cutoffs for members ≥18; for pediatrics use BMI‑for‑age percentiles per Appendix D

Clinical noteBMI calculation and diet recommendations (500–1,000 kcal/day deficit) described in Appendix D

inv-22: Obesity (adolescents) — age 17 BMI >= 95th percentile definition

Adolescent obesity (age 17) — definitionBMI ≥ 95th percentile for age and sex (per AAP pediatric BMI‑for‑age percentiles)

Policy examplesAppendix lists 95th percentile examples: age 17 male = 28.2, female = 29.6

Policy Summary

PayerHealth Net

PolicyBenzphetamine for weight management

Policy CodePolicy CP CPA.326

Change TypePeriodic annual reviewmaterial updates in 2Q2023 and 2Q2024

Effective DateJun 1, 2018

Next Review Date

Key ActionSubmit prior authorization with documentation proving BMI eligibility and at least 6 months active enrollment in a weight loss program including behavioral modification.

SourceLink

On This Page

Dose change requestsIf request is for a dose increase, the new dose must not exceed 150 mg/day (see Continued Therapy)

Tolerance noteIf tolerance develops, recommended dose should not be exceeded to increase effect; discontinue drug rather than increase dose (Appendix D)

inv-10: Weight loss program enrollment duration — Minimum active enrollment required

Minimum active enrollment (initial)>= 6 months of active enrollment in a weight loss program

Program documentationDocumentation must support participation in a program involving reduced calorie diet, increased physical activity, and behavioral modification

Guideline alignmentBehavioral modification requirement aligned with ACC/AHA guidance (added 2Q 2024)

inv-11: Adolescent obesity definition — BMI threshold for age 17

Adolescent obesity definition (age 17)For age 17 years, obesity is defined as BMI ≥ 95th percentile standardized for age and sex per AAP

Example 95th percentile valuesReported examples: age 17 male ~28.2, female ~29.6 (percentile reference values in policy appendix)

Added to policyDefinition added in 2Q 2023 annual review

Required Documentation

Providers must submit documentation supporting that the member has met all approval criteria. Acceptable documentation includes office chart notes, relevant lab results, and other clinical information demonstrating eligibility per the initial criteria.

Examples: clinic notes documenting BMI and comorbidities, enrollment records from a weight loss program, behavior modification documentation, and recent weight measurements

Documentation Required

Required Documentation for Initial Criteria

For initial approvals, documentation must include evidence that the member has been actively enrolled in a weight loss program for at least 6 months and that the program includes a reduced-calorie diet, increased physical activity, and behavioral modification. For age-based pediatric criteria, include BMI percentile documentation standardized for age and sex where applicable.

Weight loss program enrollment duration: ≥ 6 months
Program components required: reduced-calorie diet, increased physical activity, behavioral modification
Pediatric patients: BMI ≥ 95th percentile standardized for age and sex per AAP when applicable

Note

Formulary / Non‑Formulary Routing

If the requested drug use is for an indication not on the formulary or not listed in this policy, route the request per Health Net non‑formulary/no‑coverage and off‑label procedures. Refer to policy CPCPA.190 for formulary/non‑formulary routing and CP.CPA.09 for off‑label use documentation requirements when applicable.

Formulary/non‑formulary policy: CPCPA.190
Off‑label use policy: CP.CPA.09

Step Therapy

Step Therapy Note

Step therapy rules and applied therapy templates may affect approval and continued therapy decisions. Continued therapy approvals follow the plan's applied therapy process and any step‑therapy requirements must be met per Health Plan policies.

Applied therapy templates applied to other diagnoses/indications and continued therapy
Providers should verify step therapy prerequisites before submitting a prior authorization

Denial Risk

General Denial Risk

Coverage is subject to the member's benefit terms, exclusions, and limitations. Failure to meet policy criteria, lack of required documentation, or conflicts with coverage documents may result in denial of authorization or claim payment.

Coverage decisions are subject to evidence of coverage, contracts, and applicable state/federal requirements
Non‑FDA indications not addressed in this policy will be denied unless off‑label documentation per CP.CPA.09 is provided

Added to policy in 2Q 2023 annual review

inv-23: Weight loss program — definition requiring behavioral modification per ACC/AHA and minimum duration

Definition — weight loss programA program that includes reduced calorie diet, increased physical activity, and behavioral modification

Minimum duration for initial benzphetamine criteria>= 6 months of active enrollment (added 2Q 2024)

Behavioral modification standardBehavioral modification requirement referenced to ACC/AHA guideline recommendations in Appendix D

Program components guidanceAppendix D describes individualized diet planning (500–1,000 kcal/day deficit) and frequent face‑to‑face visits for best outcomes