What Is Contrave and How Does It Work?
Contrave is a prescription medication combining naltrexone and bupropion. It’s FDA-approved for chronic weight management in adults with obesity or overweight conditions with related health issues. The drug works by reducing appetite and cravings.
TRICARE covers Contrave under specific conditions. Understanding these requirements is key to getting approval.
TRICARE’s Pharmacy Benefit Overview
TRICARE offers prescription drug coverage for active duty members, retirees, and their families. The program includes most FDA-approved medications, like Contrave, when medically necessary. Coverage varies by plan, such as TRICARE Prime or Select.
Drugs are classified as generic, brand-name, or non-formulary. Contrave, a brand-name drug, often requires prior authorization.
Does TRICARE Cover Contrave for Weight Loss?
Does TRICARE cover Contrave? Yes, but only for weight management under strict criteria. You need a prescription from a licensed provider. A prior authorization form is required to confirm medical necessity.
TRICARE does not cover Contrave for other uses, such as addiction treatment. Coverage is limited to obesity or overweight with conditions like hypertension.
Eligibility Criteria for Contrave Coverage
To qualify for Contrave coverage, you must meet these requirements:
- Be 18 or older.
- Have a BMI of 30+ or 27+ with conditions like diabetes or high blood pressure.
- Have tried lifestyle changes, like diet and exercise, for at least six months.
- Participate in a health and wellness program (for active duty members).
Your doctor must document these on the prior authorization form.
Prior Authorization Process for Contrave
TRICARE requires prior authorization for Contrave to ensure it’s appropriate. Your doctor submits a form to Express Scripts, TRICARE’s pharmacy benefit manager. The form details your medical history and need for Contrave.
Without approval, you’ll pay the full cost, which can be around $600 monthly. Electronic submissions speed up the process.
How to Get the Prior Authorization Form
The form is available through the TRICARE Formulary Search Tool. Search for Contrave on the TRICARE website to find it. Your doctor can also access it via Express Scripts or CoverMyMeds.
Ensure all sections are complete. Missing details can lead to delays or denials.
Steps to Submit the Form
Submitting the prior authorization form is straightforward. Follow these steps:
- Consult Your Doctor: Discuss Contrave’s suitability for your weight loss goals.
- Fill Out the Form: Your doctor includes your BMI and prior lifestyle efforts.
- Send to Express Scripts: Submit via mail, fax, or CoverMyMeds.
- Check Status: Track approval online or call 1-800-753-2851.
Mail forms to: Express Scripts, P.O. Box 52150, Phoenix, AZ 85072-9954.
Information Required on the Form
The prior authorization form needs specific details. Your doctor must provide:
- Your personal information (name, sponsor ID, date of birth).
- BMI and related health conditions (e.g., diabetes, hypertension).
- Proof of six months of failed lifestyle changes.
- A medical necessity statement for Contrave.
Incomplete forms can cause denials. Review them with your doctor before submission.
Table: TRICARE Contrave Coverage Requirements
| Requirement | Details |
|---|---|
| Age | 18 or older |
| BMI | 30+ or 27+ with conditions like diabetes |
| Prior Efforts | 6 months of lifestyle changes (diet, exercise) |
| Program | Health and wellness program (active duty) |
| Approval | Prior authorization via Express Scripts |
This table summarizes Contrave coverage criteria.
Common Reasons for Denial
TRICARE may deny Contrave coverage if requirements aren’t met. Common issues include:
- No documentation of prior lifestyle changes.
- BMI below the required threshold.
- Incomplete or incorrect form details.
Double-check forms with your doctor. Attach all necessary medical records to avoid denials.
Appealing a Denied Request
If your request is denied, you can appeal. Your doctor submits an appeal letter with additional evidence, like updated medical records. Contact Express Scripts at 1-800-753-2851 for guidance.
Act quickly, as appeals have deadlines. Clear documentation improves approval chances.
Costs and Copays for Contrave
Once approved, Contrave is covered under TRICARE’s pharmacy benefit. Active duty members pay nothing at military pharmacies or via home delivery. Others pay $38 for a 90-day supply through TRICARE Home Delivery.
Retail pharmacy copays are higher, around $60 for 30 days. Home delivery is the most affordable option.
TRICARE Home Delivery for Contrave
TRICARE Home Delivery is cost-effective and convenient. After approval, your doctor sends the prescription to Express Scripts. You receive a 90-day supply at your door.
Enroll by completing the New Patient Mail Order Form. Mail it with your prescription to Express Scripts.
CurAccess Program for Cost Savings
If TRICARE doesn’t cover Contrave, the CurAccess Program offers savings. It costs $99 monthly with free shipping, though TRICARE beneficiaries must pay as cash customers. This doesn’t count toward TRICARE’s catastrophic cap.
Check eligibility on the Contrave website. Discuss with your doctor before enrolling.
Alternatives to Contrave
If Contrave isn’t covered, TRICARE covers other weight loss drugs. Options include:
- Phentermine: A generic option requiring a three-month trial.
- Wegovy: Covered for weight management with prior authorization.
- Zepbound: Another option with similar requirements.
Discuss alternatives with your doctor if Contrave is unavailable.
Role of Your Healthcare Provider
Your doctor is essential for securing Contrave coverage. They document your BMI, health conditions, and prior efforts. Encourage electronic submission via CoverMyMeds for faster reviews.
If issues arise, your provider can contact Express Scripts. Their expertise ensures a smoother process.
How Long Does Approval Take?
Approval times vary by submission method. Electronic submissions through CoverMyMeds take a few days. Mailed or faxed forms may take one to two weeks.
Track your request online via Express Scripts. Follow up if there’s no update within a week.
Support for Weight Management
Currax Pharmaceuticals, Contrave’s maker, offers resources through its website. These include diet and exercise tips to complement treatment. TRICARE also provides wellness programs for beneficiaries.
Ask your doctor about these resources. They can support your weight loss journey.
Staying Compliant with TRICARE Rules
After approval, follow TRICARE’s guidelines. Continue lifestyle changes like diet and exercise. Active duty members must stay enrolled in service-specific wellness programs.
Regular doctor visits ensure ongoing coverage. Non-compliance may lead to coverage loss.
Summary
Does TRICARE cover Contrave? Yes, for weight management if you meet strict criteria, including BMI thresholds and prior lifestyle efforts. Your doctor must submit a prior authorization form to Express Scripts.
Using Home Delivery and working closely with your provider ensures affordable access. Explore savings programs like CurAccess if coverage is denied.
FAQ
Does TRICARE cover Contrave for weight loss?
Yes, TRICARE covers Contrave for weight management if medically necessary. You need a BMI of 30+ or 27+ with conditions like diabetes. Prior authorization is required.
How long does Contrave prior authorization take?
Electronic submissions take a few days, while mailed forms may take one to two weeks. Track your request online. Contact Express Scripts for updates.
What if my Contrave request is denied?
You can appeal by submitting additional medical evidence. Your doctor sends an appeal letter to Express Scripts. Act quickly to meet deadlines.
Where can I find the Contrave prior authorization form?
Use the TRICARE Formulary Search Tool or get it from Express Scripts. Your doctor can access it via CoverMyMeds. Ensure all sections are complete.
How much does Contrave cost with TRICARE?
Active duty members pay nothing. Others pay $38 for a 90-day supply via Home Delivery. Retail pharmacies cost around $60 for 30 days.
What if TRICARE doesn’t cover Contrave?
The CurAccess Program offers Contrave for $99 monthly with free shipping. TRICARE users pay as cash customers. Check eligibility on the Contrave website.