Medication Prior Authorization Form — Contrave
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Form and requirements for prior authorization requests for the weight-loss medication Contrave submitted to Highmark BlueShield NE/NY; governs providers requesting PA for members in the payer's service area.
No material clinical or coverage changes in this revision.
Coverage Criteria for Contrave Prior Authorization
Authorization criteria
Coverage when ALL of the following are documented on the PA form and accompanying records:
Acceptable documentation examples listed on form (see Diet and Physical Activity categories).
Form enumerates acceptable documentation for Diet and Physical Activity.
Include dates of therapy as documented on the form.
If member is currently on a weight-loss medication, provide current height, weight, and BMI while on therapy (see continuation criteria).
This form does not list additional explicit coverage criteria on the face of the document. Coverage determinations rely on the information submitted on the completed prior authorization form and the supporting clinical documentation accompanying it.
The form does not include any explicit "not medically necessary" statements. Instead, decisions about medical necessity depend on the completeness and content of the submitted clinical documentation and the member's eligibility at the time of review; incomplete or missing documentation may prevent authorization.
Provider Submission and Documentation Requirements
Submit completed PA form and supporting documentation
Submit a completed prior authorization form (one form per medication) and all supporting clinical documentation via fax or mail. Fax the completed form and all clinical documentation to 1-866-240-8123 or mail the form to 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222.
Document prior weight‑loss medication history with dates
List prior weight‑loss medications the member has tried and include dates of therapy. Examples provided on the form include Saxenda, Qsymia, Wegovy, Xenical, Zepbound, and previous Contrave therapy.
Attach required clinical documentation (one from each category)
Provide at least one form of documentation from each required category: diet, physical activity, prior medication history, weight‑related comorbidity documentation (chart notes), and baseline (and current if applicable) height, weight, and BMI with supporting chart notes.
- Diet: provider chart notes, recurring program receipts, or member dietary logs.
- Physical activity: provider chart notes, gym receipts, wearable device summaries, or trainer receipts.
- Prior medications: list of prior weight‑loss medications with dates of therapy.
- Baseline/current vitals: height, weight, BMI with attached chart documentation.
- Weight‑related comorbidities: attach chart notes to support comorbidity entries.
Incomplete submissions or missing documentation may prevent authorization
Incomplete or missing information and supporting documentation may prevent authorization; payment is subject to member eligibility and authorization does not guarantee payment.
- Submit a separate form for each medication — incomplete submissions risk denial.
- Ensure all fields are completed and supporting chart notes/receipts are attached.
Background
Background: This prior authorization form supports requests for Contrave. Providers must submit a completed PA form (one per medication) and all supporting clinical documentation via fax to 1-866-240-8123 or by mail to the address on the form. The form requires documentation that the member will use Contrave in combination with a lifestyle modification program that includes a reduced-calorie diet and increased physical activity; acceptable evidence includes the diet and physical-activity documentation types enumerated on the form (for example, chart notes, recurring program receipts, activity logs, or wearable device summaries).
Definitions
Initial Therapy Requirements
Initial therapy
Initial therapy requirements for Contrave prior to authorization:
Acceptable documentation types are enumerated on the form (see Diet and Physical Activity lists).
Continuation Therapy Requirements
Current therapy documentation
For members currently on a weight loss medication:
Complete only the section for members currently on a weight-loss medication as indicated on the form.
Step Therapy / Prior Medication History
| Prior medication history requirement | Example agents (as listed on form) |
|---|---|
| Provide prior trial and failure history listing previous weight‑loss medications tried with dates of therapy. | Saxenda; Qsymia; Wegovy; Xenical; Zepbound; previous Contrave |
Quantity Limits
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