CurrentHighmark West VirginiaPolicy N/A

Medication prior authorization form (Contrave)

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.

Policy Summary

PayerHighmark West Virginia

PolicyMedication prior authorization form (Contrave)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax or mail the completed prior authorization form with all required clinical documentation; submit a separate form for each medication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Faxsubmission method

30/90day supply options

Requiredlifestyle documentation

1forms per medication

Coverage Criteria

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Form completion and submission: Completed medication prior authorization form submitted via fax or mail; submit a separate form for each medication; provider identification and signature included.

Fax number and mailing address must be used as instructed on the form.

Lifestyle modification documentation: Documentation demonstrating participation in a lifestyle modification program that includes reduced calorie diet and increased physical activity, with duration (months) specified; attach one supporting item from the diet category and one from the physical activity category (examples listed 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.).

Prior therapy documentation: List and provide dates of prior weight-loss medications tried and failed, if applicable (examples on the form: Saxenda, Qsymia, Wegovy, Xenical, Zepbound, previous Contrave).

Provide dates of therapy as requested on the form.

Anthropometric data: Provide baseline (prior to therapy) height, weight, and BMI; if currently on therapy, provide current height, weight, and BMI; attach supporting chart notes.

Form requests baseline measurements and, if applicable, current measurements while on therapy; attach documentation to support.

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

Prior Authorization

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

Documentation Required

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

Documentation Required

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

Documentation Required

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

Denial Risk

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.

Lifestyle program participation: Provider must indicate participation (yes/no) in a combined diet and physical activity program and provide duration in months; attach supporting documentation from both diet and physical activity categories.

The form requires one supporting item from each category and duration in months.

Baseline measurements: Provide baseline height, weight, and BMI documented prior to initiating Contrave; attach chart notes or other supporting documentation.

Baseline anthropometric data are required on the form and must be supported by documentation.

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

Lifestyle modification program

DefinitionPrograms or interventions that encourage reduced calorie diet and increased physical activity (e.g., nutritional counseling, comprehensive weight management programs).

Acceptable diet documentationProvider chart notes detailing dietary adjustments or calorie deficit; recurring receipts for subscription programs (Noom, Weight Watchers, Vida, Lark, Signos, Wondr, Livongo, Omada, Newtopia, Virta, etc.); member dietary logs; recurring appointments/receipts for private nutritional counseling or medical nutrition therapy (monthly).

Acceptable physical activity documentationProvider chart notes specifying type, duration, and frequency of activity; recurring gym membership receipts with activity notes; wearable device summary reports showing frequency/duration of activity (e.g., elevated HR >20 minutes, ≥3x/week for a month); recurring personal trainer appointment receipts and notes.

Documentation requirementOne supporting item from the diet category AND one from the physical activity category must be attached to the form; duration of participation (months) must be specified.

Purpose in authorizationEvidence of participation in a lifestyle modification program is required to support initial authorization for Contrave and must be accompanied by baseline anthropometrics and prior therapy information as applicable.

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.

Policy Summary

PayerHighmark West Virginia

PolicyMedication prior authorization form (Contrave)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax or mail the completed prior authorization form with all required clinical documentation; submit a separate form for each medication.

SourceLink

On This Page

OpenPayer

Medication prior authorization form (Contrave)

Coverage Criteria

Provider Actions & Submission Instructions

Initial Therapy Requirements

Step Therapy / Prior Medication History

Definitions

Background