ModifiedHealth NetPolicy CP.CPA.328

Diethylpropion for weight management

Medical necessity criteria, dosing, contraindications, and coverage rules for diethylpropion as a short-term adjunct to a weight-reduction program for members of Health Net/Centene lines of business.

Policy Summary

PayerHealth Net

PolicyDiethylpropion for weight management

Policy CodePolicy CP.CPA.328

Change TypeClarified continuation response criteriareferences updated

Effective Date06.01.18

Next Review Date

Key ActionSubmit prior authorization with documentation of BMI, enrollment in a weight‑loss program, and evidence of weight loss (adults) or BMI reduction (pediatrics) for continued therapy.

SourceLink

POLICY UPDATE CHANGES

For continued therapy, clarified positive response as evidenced by weight loss for adults and added reduction of BMI for pediatrics.

References reviewed and updated.

≥30 / ≥27 w/ comorbAdult BMI threshold

12 weeksMax treatment duration

75 mg/dayMax daily dose

IR:25mg TID; ER:75mg QDDosing regimens

≥16 yrsAge requirement

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Coverage Criteria for Diethylpropion

Initial Therapy

Covered when ALL of the following are met:

Initial Approval - Weight Management: 1. Member meets one of the following: (a) BMI ≥ 30 kg/m2; (b) BMI ≥ 27 kg/m2 with at least one indicator of increased cardiovascular risk (e.g., coronary artery/heart disease, hypertension, dyslipidemia, diabetes, elevated waist circumference) or other obesity-related medical condition (e.g., sleep apnea); (c) if age < 18 years: BMI ≥ 95th percentile standardized for age and sex (see Appendix D).see text

Pediatric percentiles provided in Appendix D.

Initial Approval - Age: 2. Age ≥ 16 years.>=16 years

Age requirement per policy; revised in annual reviews.

Initial Approval - Program participation: 3. Documentation supports participation in a weight loss program that includes reduced calorie diet, increased physical activity, and behavioral modification, with both: (a) actively enrolled for at least 6 months; and (b) will continue to be actively enrolled adjunct to therapy.>=6 months

Behavioral modification and enrollment duration required.

Initial Approval - Dosing limits: 4. Dose does not exceed: (a) 75 mg per day; (b) Immediate release (IR): 3 tablets per day; (c) Extended release (ER): 1 tablet per day.75 mg/day

Maximum daily dose and formulation limits.

Continuation Therapy

Continued therapy is covered when ALL of the following are met:

Continued Therapy - Prior exposure: 1. Member is currently receiving medication via the Centene benefit or previously met initial approval criteria; or continuity of care applies per state/product addendums (see CC.PHARM.03A and CC.PHARM.03B).

Refer to state-specific continuity of care addendums as applicable.

Continued Therapy - Response: 2. Member is responding positively to therapy as evidenced by weight loss (adults) or reduction in BMI (pediatrics) from baseline.

Clarified in 2Q2026 annual review that response = weight loss for adults and BMI reduction for pediatrics.

Continued Therapy - Program participation: 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.

Same program participation requirements as initial approval.

Non‑FDA approved indications that are not specifically addressed by this clinical policy are excluded from coverage unless the request is supported by adequate documentation of efficacy and safety consistent with the Health Net off‑label use policy (CP.CPA.09) or other applicable coverage documents.

Coverage under this clinical policy is governed by the member's specific benefit plan. All coverage determinations remain subject to the terms, conditions, exclusions, and limitations of the member's contract and any applicable legal or regulatory requirements; this policy does not guarantee payment and the Health Plan may change, amend, or withdraw the policy as allowed by contract and law.

Therapy is considered medically inappropriate and will trigger denial when used in the presence of listed contraindications. Known contraindications include: pulmonary hypertension, advanced arteriosclerosis, hyperthyroidism, glaucoma, severe hypertension, agitated states, history of drug abuse, concurrent use of other anorectic agents, use or recent use (within 14 days) of monoamine oxidase inhibitors (MAOIs), and known hypersensitivity to sympathomimetic amines. Additionally, if tolerance develops, dose escalation in lieu of discontinuation is not appropriate.

Dosing, BMI Thresholds, and Coding-related Values

BMI thresholds — Adults and Pediatrics

Adult BMI thresholdBMI ≥ 30 kg/m2, or BMI ≥ 27 kg/m2 with ≥1 obesity-related condition (e.g., coronary artery disease, hypertension, dyslipidemia, diabetes, elevated waist circumference) or other obesity-related medical condition (e.g., sleep apnea)

Pediatric thresholdBMI ≥ 95th percentile for age and sex (see Appendix D for percentile values and examples)

Age requirementAge ≥ 16 years for initial approval

Maximum dose and dosing regimens (IR/ER)

Maximum daily dose75 mg per day

Immediate-release (IR) regimen25 mg PO three times daily (IR: 3 tablets/day)

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required — Initial approval documentation required

Prior authorization is required. Provider must submit documentation (such as office chart notes, lab results, or other clinical information) supporting that the member has met all approval criteria. This includes evidence of participation in a weight-reduction program and any other documentation referenced in the policy.

Submit office notes, baseline and follow-up weights/BMI, and results of relevant labs as applicable
Document participation in a structured weight-management program for at least 6 months and ongoing enrollment
Support positive response for continuation requests (adult weight loss or pediatric BMI reduction)
Include dosing information and ensure requested dose does not exceed policy limits (≤75 mg/day; IR ≤3 tablets/day; ER ≤1 tablet/day)

Documentation Required

Prior Authorization — Continued therapy documentation and evidence of positive response required

Background on Diethylpropion

Diethylpropion is a sympathomimetic amine with pharmacologic similarities to amphetamines. It is indicated as a short‑term adjunct (generally a few weeks) to caloric restriction and lifestyle modification for the management of exogenous obesity in appropriately selected patients, and is intended to be used together with reduced calorie diet, increased physical activity, and behavioral modification.

Definitions and Reference Values

Definition of BMI and pediatric percentile reference

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

Pediatric referenceUse 95th percentile BMI values standardized for age and sex (see Appendix D for table of values)

Examples providedAppendix D lists 95th percentile BMI values for ages ~16–17.5 years by sex (e.g., age 17 male = 28.2, female = 29.6)

Contraindications list (definition-style quick reference)

Primary contraindicationsPulmonary hypertension; advanced arteriosclerosis; hyperthyroidism; glaucoma; severe hypertension; agitated states

Addiction and drug interactionsHistory of drug abuse; concurrent use of other anorectic agents; concomitant use or use within 14 days of MAO inhibitors

Policy Summary

PayerHealth Net

PolicyDiethylpropion for weight management

Policy CodePolicy CP.CPA.328

Change TypeClarified continuation response criteriareferences updated

Effective Date06.01.18

Next Review Date

Key ActionSubmit prior authorization with documentation of BMI, enrollment in a weight‑loss program, and evidence of weight loss (adults) or BMI reduction (pediatrics) for continued therapy.

SourceLink

On This Page

Continued Therapy - Duration: 4. Total treatment duration does not exceed 12 weeks.<=12 weeks

Therapy is intended as short-term adjunctive treatment.

Continued Therapy - Dose: 5. If request is for a dose increase, the new dose must not exceed: (a) 75 mg per day; (b) IR: 3 tablets per day; (c) ER: 1 tablet per day.75 mg/day

Dosing limits reiterated for renewals.

Extended-release (ER) regimen75 mg PO once daily (ER: 1 tablet/day)

Product availabilityIR tablet: 25 mg; ER tablet: 75 mg

For continuation of therapy, documentation must show clinical benefit from diethylpropion. Providers should include objective measures (weight or BMI change from baseline) and confirm ongoing enrollment in a weight-management program. Total treatment duration for weight management does not exceed 12 weeks per policy for continuation.

Provide baseline and most recent weight/BMI and describe response to therapy
Confirm continued participation in a reduced-calorie, increased-activity, behavioral modification program
If requesting a dose increase, show that new dose remains within policy limits

Denial Risk

Non‑covered Indications

Requests for uses that are not FDA-approved and not listed in the policy will be denied unless sufficient supporting documentation is provided per off-label use policy. If the drug's label has recently changed and that change is not reflected in this policy, follow the formulary/no-coverage or non-formulary guidance referenced below.

Non‑FDA approved indications are not authorized absent documentation of efficacy/safety per CP.CPA.09
If there is a recent label change not yet in this policy: follow CP.CPA.190 or applicable non-formulary policy as directed in the policy

Denial Risk

Contraindications — use is contraindicated in listed conditions

Use of diethylpropion is contraindicated in the listed conditions. Providers must verify contraindications (e.g., pulmonary hypertension, advanced arteriosclerosis, hyperthyroidism, glaucoma, severe hypertension, agitated states, history of drug abuse, concurrent use of other anorectic agents, concomitant use or use within 14 days of MAO inhibitors, and known hypersensitivity to sympathomimetic amines) prior to prescribing.

Do not initiate therapy in patients with any listed contraindication
Document review of contraindications in the chart

Note

Coverage decisions subject to plan terms and applicable laws/regulations

Coverage decisions are made in accordance with the terms of the member's benefits and are subject to applicable legal and regulatory requirements. This clinical policy is a guide to coverage determinations and does not replace provider clinical judgment or guarantee payment.

Where policy and law/regulation conflict, legal/regulatory requirements govern
The Health Plan may change, amend or withdraw this policy at any time
Providers remain responsible for medical judgment and for documenting the medical necessity of requested treatment

HypersensitivityKnown hypersensitivity to sympathomimetic amines

Tolerance guidanceIf tolerance develops, do not exceed recommended dose — discontinue rather than escalate dose

Health Plan definition

Definition of Health PlanA health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan's affiliates

Policy purposeProvides a guide to medical necessity to assist coverage decisions and benefit administration; not a contract or guarantee of payment

Coverage decisions scopeSubject to all terms, conditions, exclusions, and limitations of the coverage documents and applicable state/federal requirements