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| Category: | Prior Authorization |
| Number: | J-0002 |
| Subject: | Wellbutrin® |
| Effective Date Begin: | June 1, 2002 |
| Effective Date End: | June 3, 2003 |
| Original Date: | March 1, 1999 |
| Review Date(s): | June 1, 2001 |
| June 1, 2000 | |
This policy applies to those members whose prescription drug benefits exclude or require prior authorization of smoking cessation therapy.
Background:
Bupropion is an oral antidepressant agent. It is available in both immediate-release (Wellbutrin) and sustained-release (Wellbutrin SR) dosage forms. Both Wellbutrin and Wellbutrin SR are indicated in the treatment of depression.
Bupropion is also available under the proprietary name Zyban. Zyban is an oral sustained-release dosage form containing bupropion 150 mg. Zyban is indicated as an aid to smoking cessation treatment; it is not indicated in the treatment of depression.
Many groups do not include smoking cessation therapy as part of their prescription drug benefit. However, both Wellbutrin SR and Zyban are available as 150 mg sustained-release tablets. Thus, the opportunity exists to obtain coverage for Wellbutrin SR and to then utilize this medication as an aid in smoking cessation treatment for those members who do not have coverage for smoking cessation therapy. Therefore, Wellbutrin and Wellbutrin SR requires prior authorization.
Approval Criteria: For groups that exclude coverage for smoking cessation, the following indication will be applied for the coverage of Wellbutrin and Wellbutrin SR therapy:
1.Any medical condition with the exception of smoking cessation therapy.
Use of Wellbutrin and Wellbutrin SR for smoking cessation treatment will be denied to prevent the circumvention of established benefit exclusions.
Duration of Authorization:
If approved, authorization should be granted for a period of one year.
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Pharmacy policies do not constitute medical advice, nor are they intended to govern physicians' prescribing or the practice of medicine. They are intended to reflect Highmark's coverage and reimbursement guidelines. Coverage may vary for individual members, based on the terms of the benefit contract.
Highmark retains the right to review and update its pharmacy policy at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the pharmacy policies is prohibited; however, limited copying of pharmacy policies is permitted for individual use.
