Updated: 08/2017 DMMA Approved: 11/2017

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Antonia Gibbs
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1 Request for Prior Authorization for Therapy to Treat Binge Eating Disorder Website Form Submit request via: Fax All requests for medications to treat Binge Eating Disorder (BED) require prior authorization and will be screened for appropriateness using the criteria below. Therapy to treat Binge Eating Disorder Prior Authorization Criteria: The member is 18 years of age or older; AND Must be prescribed by, or in consultation with, a psychiatrist or psychiatric nurse practitioner; AND The member must meet DSM-V criteria for Binge Eating Disorder (BED) including all of the following: o Recurrent episodes of binge eating characterized by both of the following: eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances; AND a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) o The binge eating episodes are associated with three (3) or more of the following: Eating much more rapidly than normal Eating until feeling uncomfortably full Eating large amounts of food when not feeling physically hungry Eating alone because of feeling embarrassed by how much one is eating Feeling disgusted with oneself, depressed, or very guilty afterward; AND o Marked distress regarding binge eating is present; AND o The binge eating occurs on average at least once per week for 3 months; AND o Absence of compensatory behaviors, such as purging or excessive exercise; AND BED is classified as moderate to severe (moderate: 4-7 binge eating episodes per week; severe: 8-13 binge eating episodes per week) with the number of binge episodes per week documented; AND The prescriber has checked the PMP profile for the member and confirmed the member is not concurrently on opioids, benzodiazepines, or stimulants; AND If requesting Vyvanse, the member does not have known hypersensitivity to amphetamine products and is not taking or has not taken monoamine oxidase inhibitors (MAOIs) in the past 14 days; AND The member does not have cardiac disease (coronary artery disease, serious heart arrhythmias, structural cardiac abnormalities, cardiomyopathy); AND The prescribed medication is not being used for weight loss or to treat obesity; AND The member does not have a history of substance abuse and the informed consent for CNS stimulants has been submitted; AND Documentation of non-pharmacologic therapies (such as cognitive-behavioral therapy and/or interpersonal therapy with a clinician) within the past 6 months o Attestation the member will continue cognitive behavioral therapy or interpersonal therapy with a clinician while on pharmacologic agents; AND

2 If requesting Vyvanse, the starting dose is 30mg/day titrated in increments of 20mg at least 1 week apart to reach a target dose of 50-70mg/day but not to exceed 70mg/day. When criteria is met, initial benefit is approved for 16 weeks. For Reauthorization: Documentation submitted shows an improvement from baseline in the number of binge days per week; AND Documentation the member is continuing to receive cognitive behavioral therapy or interpersonal therapy with a clinician while on pharmacologic agents, AND If requesting Vyvanse, the dose requested is not exceeding 70mg/day. When criteria is met, benefit is approved for 6 months. Coverage may be provided for any non-fda labeled indication if it is determined that the use is a medically accepted indication supported by nationally recognized pharmacy compendia or peer-reviewed medical literature for treatment of the diagnosis(es) for which it is prescribed. These requests will be reviewed on a case by case basis to determine medical necessity.

3 Therapy to Treat Binge Eating Disorder PRIOR AUTHORIZATION FORM Please complete and fax all requested information below including any progress notes, laboratory test results, or chart documentation as applicable to Health Options Pharmacy Services. FAX: If needed, you may call to speak to a Pharmacy Services Representative. PHONE: PROVIDER INFORMATION Requesting Physician: NPI: Physician Specialty: Office Address: Member Name: Health Options ID: Medication: Frequency: Diagnosis: Office Contact: Office Phone: Office Fax: MEMBER INFORMATION DOB: DRUG INFORMATION Strength: Duration: MEDICAL HISTORY ICD-10 code: Does the member have both characteristics of recurrent episodes of binge eating: eating in a discrete period of time an amount of food definitely larger than most would eat in a similar period of time and a sense of lack of control over eating during the episode? Yes No Do the binge eating episodes have three (3) or more of the following (check all that apply)? Eating until uncomfortably full Eating more rapidly than normal Eating large amounts when not physically hungry Eating alone out of embarrassment Feeling disgusted, depressed, or guilty after eating Is there marked distress regarding binge eating? Yes No Does the member binge eat on average at least once per week for 3 months? Yes No Is there the absence of compensatory behaviors, such as purging or excessive exercise? Yes No Is the members BED classified as moderate to severe? Yes No Baseline number of binge eating episodes per week: Does the member have a history of hypersensitivity to amphetamines? Yes No Is the member taking or has taken in the past 14 days a monoamine oxidase inhibitor? Yes No Does the member have a history of cardiovascular disease or has developed cardiac disease while on therapy? Yes, diagnosis No Does the member have a history of substance abuse? Yes No Has the member signed an Informed Consent form for CNS Stimulants? Yes No The PMP profile has been checked for this member? No Yes (complete the following statement) The member is is not on opioids, benzodiazepines, or stimulants. For reauthorization: Current number of binge eating episodes per week while on treatment: Is the member continuing to receive non-pharmacologic therapy while on Vyvanse? Yes No PREVIOUS AND CURRENT NON- PHARMACOLOGIC AND PHARMACOLOGIC THERAPY Description/type of therapy Dates of Therapy Status (Discontinued & Why or Current)

4 ADDITIONAL SUPPORTING INFORMATION or CLINICAL RATIONALE Prescribing Physician Signature Date

5 Informed Consent form for CNS Stimulants Updated: 08/2017 The purpose of this agreement is to give you information about the medications you will be taking for Binge Eating Disorder (BED) and to assure that you and your physician/health care provider comply with all state and federal regulations concerning the prescribing of controlled substances. I have agreed to use a CNS amphetamine derived stimulant for the treatment of BED. I understand that these drugs can be safe and useful, but have a high potential for misuse and are therefore closely controlled by the local, state, and federal government. By signing this document I acknowledge that: 1. I understand these medications are controlled substances. They are highly regulated by state and federal law because of their potential for abuse, misuse, addiction, and diversion. a) I understand that it is a felony to acquire these medications inappropriately without a prescription or to give or sell them to anyone. 2. I will not request other controlled medication prescriptions from any other prescriber. Any controlled prescriptions will be written by only one regular prescriber a. I acknowledge that mixing stimulant medications with other prescription medications, over-the counter medications, alcohol, or other drugs can be dangerous. i. I will inform my physician of all medications I am taking, including herbal remedies. Medications like Valium, Ativan, Xanax, or Klonopin; nasal decongestants such as pseudoephedrine; herbal products, alcohol, and cough syrups can interact with my medication. b. I will not use any illicit substances, such as cocaine, marijuana, etc. while taking this medication. This may result in a change to my treatment plan, including safe discontinuation of my medications or complete termination of the doctor/patient relationship. c. If I develop anxiety or panic attacks while on this medication, I agree this medication will be decreased or changed. A medication such as a benzodiazepine will not be prescribed to treat a side effect since dangerous interactions and overdoses have occurred that way. 3. I agree to take the medication only as prescribed. a. I understand that decreasing or stopping my medication without the close supervision of my physician can lead to depression and withdrawal. b. I understand that increasing my dose without the close supervision of my physician could lead to drug hypertensive crisis, overdose, or even death. c. If I do not use all of the medication prescribed on a monthly basis, I will let my physician know at my next visit how many tablets I have left and what days I don't need medication. d. I take full responsibility to secure both the prescription and the medication safely so that they are not misplaced, lost, or misused by others.

6 4. I am aware of the side effects of taking a controlled schedule II substance for BED. This medication can produce side effects including, but not limited to, insomnia, headache, cardiovascular issues, and emotional issues psychosis, and tolerance. Addiction is also a risk if this medication is used other than its prescribed use, or in dosages above those prescribed. By signing this document, I acknowledge I have read the above information, that I will abide by all parts of it and that failure to do so will result in termination of my stimulant medication. PRINTED NAME: SIGNATURE: DATE:

Calcitonin Gene Related Peptide Receptor Inhibitors Prior Authorization Criteria:

Request for Prior Authorization for Calcitonin Gene Related Peptide Receptor Inhibitors Website Form www.highmarkhealthoptions.com Submit request via: Fax - 1-855-476-4158 All requests for Calcitonin Gene