Request For Prior Authorization printable pdf download

Request for Prior Authorization for therapy to treat Binge Eating Disorder

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Submit request via: Fax - 1-855-476-4158

All requests for medications to treat Binge Eating Disorder (BED) require prior authorization and will be

screened for appropriateness using the criteria below.

Initial Prior Authorization

 The patient is 18 to 65 years of age

 The prescriber is a psychiatrist or psychiatric nurse practitioner.

 The prescriber has checked the PMP profile for the patient and confirmed the patient is not concurrently

on opioids, benzodiazepines, or stimulants.

 The patient does not have hypersensitivity to amphetamines.

 The patient is not taking or has not taken monoamine oxidase inhibitors (i.e. Marplan, Parnate,

Phenelzine Sulfate, Tranylcypromine Sulfate, Azilect, EMSAM, Selegiline) in the past 14 days.

 The patient does not have cardiac disease (coronary artery disease, serious heart arrhythmias, structural

cardiac abnormalities, cardiomyopathy)

 The prescribed medication is not being used for weight loss or to treat obesity.

 The patient has a BMI of 25 to 45.

 The patient does not have a history of substance abuse and the informed consent for CNS stimulants has

been submitted.

 Documentation is submitted supporting the diagnosis of moderate to severe BED and the number of

binge episodes per week. Binge Eating Disorder encompasses eating an abnormally large amount of

food, feeling a lack of control during binging, occurs at least once a week for at least 3 months, and is

not associated with behaviors of purging, laxative use, or excessive exercise. In addition, the patient

experiences recurrent episodes of 3 or more of the following criteria: eating rapidly, eating until

uncomfortably full, eating large amounts when not hungry, eating alone out of embarrassment, feeling

guilty depressed or guilty after eating.

 Documentation and outcomes are submitted of non-pharmacologic therapies (such as cognitive-

behavioral therapy and/or interpersonal therapy with a clinician at least once a week) within the past 6

months for a 3 month timeframe

o Confirmation that patient will continue cognitive behavioral therapy or interpersonal therapy

with a clinician at least once a week while on pharmacologic agents.

 Documentation and outcomes are submitted of any pharmacologic therapies tried within the past 6

months for a 3 month timeframe. Other agents that have had success for BED: Zonisamide,

Topiramate, Venlafaxine, Citalopram, Sertraline, Fluvoxamine

 If the patient meets these requirements then Prior Authorization will be granted for a 4- month trial of an

authorized product at a standard dose. Requests for renewal must include documentation of a change

from baseline at week 12 in the number of binge days per week. Vyvanse will not continue to be

authorized if the patient does not show improvement of binge eating episodes.

 Vyvanse starting dose is 30mg/day titrated in increments of 20mg at least 1 week apart to reach a target

dose of 50-70mg/day not to exceed 70mg/day.

Request For Prior Authorization