Policy Applies to

• Commercial members whose prescription drug benefits exclude coverage of nicotine cessation therapy or require prior authorization of nicotine cessation therapy.

Drugs Addressed in this Policy

• Wellbutrin
• Wellbutrin SR
• Wellbutrin XL
• Bupropion
• Bupropion SR
• Bupropion XL
• Aplenzin
• Forfivo XL

FDA-Approved Indication(s)

Major Depressive Disorder (ICD-9 311, ICD-9 296.3, ICD-10 F33.x, ICD-10 F32.9)	Wellbutrin
	Wellbutrin SR
	Wellbutrin XL
	Bupropion
	Bupropion SR
	Budeprion XL
	Aplenzin
	Forfivo XL

Seasonal Affective Disorder (SAD, ICD-9 296.99, ICD-10 F34.8):  Wellbutrin XL and Aplenzin

Background

Bupropion is an oral antidepressant agent available in immediate-release, sustained-release and extended release dosage forms; please see above for FDA approved diagnosis information. Bupropion is also available under the proprietary name Zyban® which is an oral sustained-release formulation indicated as an aid to nicotine cessation therapy solely.  Zyban® does not carry the labeled FDA approved indication for depression or SAD. Many groups do not include smoking cessation therapy as part of their prescription drug benefit.  To prevent the use of bupropion containing products for nicotine cessation therapy when there is no coverage under the prescription drug benefit, groups may choose to prior authorize any bupropion containing product to ensure that it is being used for non-nicotine cessation purposes.

Approval Criteria

For groups that exclude coverage for nicotine cessation therapy, bupropion products may be covered if all of the following criteria are met:

• Bupropion products (listed above) are being used for any FDA-approved indication with the exception of smoking cessation therapy.

Duration of Authorization
If approved, up to a lifetime authorization may be granted.

 

References

1. Bupropion (Wellbutrin) prescribing information. GSK. Research Triangle Park, NC. 2014.
2. Bupropion (Aplenzin, Wellbutrin, Zyban). Clinical Pharmacology. Tampa, FL: Gold Standard Multimedia; 2006. Updated August 11, 2016.
3. Bupropion (Wellbutrin). DRUGDEX System. New York: Thomson Reuters; 2015. Last Modified: December 15, 2016.