CurrentmhnPolicy HNCA.CP.PCH.12

Clinical Policy: Bupropion/Naltrexone (Contrave)

Clinical policy governing medical necessity and coverage considerations for the extended-release combination product bupropion/naltrexone (Contrave) for management of overweight and obesity for members covered by the Health Plan.

Policy Summary

Payermhn

PolicyClinical Policy: Bupropion/Naltrexone (Contrave)

Policy CodePolicy HNCA.CP.PCH.12

Change TypeClarified contraindicationadded documentation requirements

Effective DateMay 1, 2017

Next Review Date

Key ActionObtain and submit documentation of current height and weight within 30 days and evidence of enrollment in a behavioral weight loss program when requesting prior authorization.

SourceLink

POLICY UPDATE CHANGES

For indicators of increased cardiovascular risk, clarified that hypertension should be 'controlled' due to contraindication for uncontrolled hypertension.

Documentation of current height and weight within the last 30 days was added to initial criteria; for reauthorization, only current weight within the last 30 days is required.

8 mg / 90 mgproduct strength (naltrexone/bupropion) available

Week 4: 2 tablets BIDmaintenance dosing regimen (per titration schedule)

Updated May 2024latest referenced prescribing information

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Coverage Criteria for Bupropion/Naltrexone (Contrave)

Initial Therapy

Covered when ALL of the following are met:

Initial Authorization: Member has documentation of current height and weight within the past 30 days; member is actively enrolled in a weight loss program that includes behavioral modification (member has been actively enrolled for at least 6 months as noted in recent updates); prescriber documents a lifestyle modification plan and schedules follow-up to assess adherence and response; cardiovascular risk assessment shows hypertension is controlled (uncontrolled hypertension is a contraindication).see documentation recency

Examples of approved weight loss programs and WHO weight classification added to appendices.

Continuation Therapy

Covered for continuation when ALL of the following are met:

Reauthorization: Documentation includes current weight within the last 30 days and evidence of clinical response and adherence as assessed at follow-up visits; prior continued-therapy requirement for BMI ≥ 25 kg/m2 has been removed (2Q 2023).weight within 30 days

Continued therapy BMI criterion removed in 2Q 2023.

Uncontrolled hypertension is a formal contraindication to therapy and is excluded from coverage while present. Providers must ensure and document that the member’s hypertension is controlled before initiating or continuing bupropion/naltrexone; if hypertension is uncontrolled or not documented as controlled, the request may be denied.

Use of bupropion/naltrexone is not covered for members with uncontrolled hypertension and may be considered not medically necessary when required supporting documentation is missing. Initial authorization requires documentation of enrollment in a behavioral weight loss program that includes behavioral modification and recent clinical measurements; absence of documentation that hypertension is controlled or that the member is actively participating in the required behavioral program will preclude approval.

Coding and Documentation Recency

Affected codes (placeholder)mixed

affected codes

Policy references affected codes for prior authorization (document lists 'affected codes' placeholder in this part of the document).

Documentation recency (required measurements)

Initial authorization documentation windowHeight and weight documented within the past 30 days is required for initial authorization.

Reauthorization documentation windowCurrent weight documented within the past 30 days is required for reauthorization/continuation.

Purpose of recency requirementEnsures baseline and follow-up measurements are current for assessment of clinical response and adherence.

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior Authorization Required — Prior authorization is required and will be approved only when the member meets the clinical criteria, required documentation is submitted, and cardiovascular risk assessment is documented.

Prior auth requires meeting all clinical criteria in the policy
Submit documentation listed in Required Clinical Documentation callout
Document cardiovascular risk assessment and show hypertension is controlled when applicable

Note

Behavioral Program Requirement

Behavioral weight‑loss program enrollment is required as part of the treatment plan. The member should be actively enrolled in a behavioral program that includes lifestyle modification and behavioral counseling consistent with ACC/AHA guidance.

Examples of HN-approved programs: Diabetes Prevention Program (DPP), commercial programs with documented behavioral counseling components, structured multidisciplinary weight‑management programs offered by health systems or specialty clinics

Background

Bupropion/naltrexone (Contrave) is an extended‑release combination product indicated as an adjunct to lifestyle modification for chronic weight management. The tablet contains 8 mg naltrexone / 90 mg bupropion and is titrated to a maintenance regimen of two tablets taken orally twice daily by week 4. Coverage requires concurrent lifestyle modification and documentation of participation in a behavioral weight loss program as described in the policy.

Product Strength and Dosing

Contrave strength and maintenance dosing (titration)

Tablet strengthExtended‑release tablet contains 8 mg naltrexone / 90 mg bupropion.

Maintenance dosing (target)Titrate to maintenance dosing of 2 tablets orally twice daily (2 tablets PO BID) by Week 4.

Titration schedule (week 3)Week 3: Two tablets PO QAM and one tablet PO QPM.

Onward dosing from week 4Week 4 and onward: 2 tablets PO BID.