Medication prior authorization form (Contrave)
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Form and instructions to request prior authorization for Contrave (naltrexone/bupropion) for Highmark West Virginia members; used by prescribing providers to submit clinical and administrative information to support coverage.
No material clinical or coverage changes in this revision.
Coverage Criteria
Authorization supporting criteria
Authorization will be supported when ALL of the following are provided with the form:
Fax number and mailing address must be used as instructed on the form.
Acceptable diet and physical activity documentation examples are specified on the form (provider chart notes, recurring receipts, dietary logs, wearable device reports, etc.).
Provide dates of therapy as requested on the form.
Form requests baseline measurements and, if applicable, current measurements while on therapy; attach documentation to support.
The form does not list any explicit clinical exclusions. Reviewers should rely on the form’s required documentation and clinical judgment; if a specific exclusion is suspected, standard medical necessity criteria and drug labeling should be consulted.
If the required documentation showing participation in a lifestyle modification program (diet and physical activity) or prior weight‑loss medication history with dates is not provided, the request will be considered insufficient and may be denied. The form explicitly requests attachment of supporting documentation for program participation and prior therapies, and absence of these attachments constitutes a missing required element.
Provider Actions & Submission Instructions
Submission and form requirement
Fax the completed Medication Prior Authorization Form and all clinical documentation to 1-866-240-8123, or mail to: 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222. Submit a separate form for each medication. Print, type, or write legibly in blue or black ink. Complete ALL information on the form. The prescribing physician (PCP or Specialist) should, in most cases, complete the form. Provide the physician address as it is required for physician notification.
- Submit a separate form for each medication
- Fax: 1-866-240-8123
- Mail: 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222
- Complete all fields; legible in blue or black ink
- Prescribing physician should complete form in most cases
- Provide physician address for notification
Required clinical documentation
Attach documentation supporting participation in a lifestyle modification program that includes both reduced calorie diet and increased physical activity. One form of documentation is required from each category (Diet and Physical Activity). Acceptable diet documentation includes: provider chart notes detailing dietary adjustments or calorie deficit; recurring receipts for a subscription to a lifestyle program (e.g., Noom, Weight Watchers, Vida, Lark, Wondr, Omada, etc.) provided monthly; a dietary log maintained by the member; or recurring appointments/receipts for private nutritional counseling or medical nutrition therapy. Acceptable physical activity documentation includes: provider chart notes specifying type, duration and frequency; recurring gym membership receipts plus activity notes; summary reports from wearable devices (e.g., elevated heart rate >20 minutes at least 3x/week for a month); or recurring personal trainer appointments/receipts with activity notes.
- Require one supporting document from Diet category and one from Physical Activity category
- Diet examples: chart notes, program subscription receipts (monthly), dietary logs, recurring nutrition counseling receipts
- Physical activity examples: chart notes, gym membership receipts with activity details, wearable device reports, personal trainer receipts
Provider identification
Provide physician information on the form including: Physician's name, NPI, phone, fax, full practice address (including suite/building if applicable), city, state, zip code, physician signature, and date. The physician address is required for physician notification.
- Physician name and NPI
- Phone and fax
- Full address (suite/building if applicable), city, state, zip
- Physician signature and date
Member identification
Provide member identifying information: Subscriber ID number, Subscriber group number, Member name, Phone, Date of birth, and full address (city, state, ZIP).
- Subscriber ID number
- Subscriber group number
- Member name and date of birth
- Member phone and full address
Prior medication trial documentation
List any prior weight-loss medications the member has tried and failed, with dates of therapy. Examples include Saxenda, Qsymia, Wegovy, Xenical, Zepbound, previous Contrave therapy, etc. Provide dates for each listed medication and attach supporting documentation (e.g., chart notes, prescription records).
- List prior weight-loss medications tried and failed with dates
- Attach supporting documentation (chart notes, prescription history)
Initial Therapy Requirements
Initial therapy requirements
Initial authorization support requires documentation of lifestyle modification and baseline metrics.
The form requires one supporting item from each category and duration in months.
Baseline anthropometric data are required on the form and must be supported by documentation.
Step Therapy / Prior Medication History
| Step | Requirement |
|---|---|
| 1 | Prior medication history must be provided on the form — list prior weight‑loss medications tried and failed with dates (e.g., Saxenda, Qsymia, Wegovy, Xenical, Zepbound, previous Contrave). |
Definitions
Background
The intake form is designed to capture clinical evidence that the member has engaged in a lifestyle modification program and to document baseline anthropometrics. Specifically, the form asks whether the member will use Contrave in combination with a program that encourages a reduced‑calorie diet and increased physical activity, requests the duration of participation in months, and requires attachments from both a diet category (for example, provider chart notes, dietary logs, or recurring program receipts) and a physical activity category (for example, chart notes, gym membership receipts, wearable device reports). The form also requires baseline (prior to therapy) height, weight, and BMI, with chart notes attached; for members currently on a weight‑loss medication, current height, weight, and BMI are requested as well. The completed form and all clinical documentation must be faxed or mailed as instructed, and a separate form must be submitted for each medication.
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