CurrentAdvanced HealthPolicy N/A

Medications for Weight Management Drug Use Criteria

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Establishes initial and renewal coverage criteria for FDA-approved weight management medications and supported compendia use for Advanced Health Oregon Health Plan members.

Policy Summary

PayerAdvanced Health

PolicyMedications for Weight Management Drug Use Criteria

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionDocument at least six months of comprehensive, intensive behavioral interventions before initial authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Age 8+Minimum age for pharmacologic treatment

6 monthsBehavioral intervention before initial approval

BMI ≥30Adult BMI threshold

95th percentilePediatric BMI threshold

MPR ≥80%

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CurrentAdvanced HealthPolicy N/A

Medications for Weight Management Drug Use Criteria

Customize your policy alerts

Sign up for all advancedhealth policy alerts

Know when advancedhealth releases new policies or updates existing guidance.

Monitor payer policy activity

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Establishes initial and renewal coverage criteria for FDA-approved weight management medications and supported compendia use for Advanced Health Oregon Health Plan members.

Policy Summary

PayerAdvanced Health

PolicyMedications for Weight Management Drug Use Criteria

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionDocument at least six months of comprehensive, intensive behavioral interventions before initial authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Age 8+Minimum age for pharmacologic treatment

6 monthsBehavioral intervention before initial approval

BMI ≥30Adult BMI threshold

95th percentilePediatric BMI threshold

MPR ≥80%

Renewal adherence threshold

6 monthsMaximum authorization period

Coverage Criteria

Initial Therapy

Covered for an initial request when ALL required criteria below are met.

ALL of the following

ONE of the following
- Primary weight-reduction use with age requirement
  - The medication is prescribed for the primary purpose of reducing weight for the member.
  - The member is 20 years of age or younger.
- The member has a covered comorbid condition that allows coverage of the medication, such as diabetes.
The member is age 8 or older.
If the member is under age 8, deny as not meeting criteria or send for MD review. Pharmacologic treatment is not medically appropriate for children under age 8 per the American Academy of Pediatrics Clinical Practice Guidelines.
The member has been engaged in comprehensive, intensive behavioral interventions for at least six months.
Adequate documentation is required.
The member, parent, or caregiver is actively participating in a lifestyle or nutrition support program.
Attestation is required.
The medication is prescribed in a manner supported by the FDA-approved indication and dosing recommendations based on age, or the medication is supported by compendia.
Off-label use of medication is not a covered benefit under the Oregon Health Plan.
ONE of the following BMI criteria
- The member's BMI is greater than or equal to 30 kg/m².
- If under 18, the member's initial BMI is at or above the 95th percentile for age and sex.
- Lower BMI with risk factors
  - The member's BMI is less than 30 kg/m², or, if under 18, the member's initial BMI is less than the 95th percentile for age and sex.
  - The member has one or more cardiovascular disease risk factors: diabetes, hypertension, or dyslipidemia.
- The member does not meet the preceding BMI criteria; send for MD review for medical appropriateness and necessity.
The member has trialed and failed all appropriate less costly alternative therapies.
If not, deny as not meeting criteria and require a trial of less costly options; the reviewer should list the appropriate less costly alternatives.

Continuation Therapy

Covered for renewal when ALL of the following criteria are met.

ALL of the following

The member is adherent to therapy.MPR ≥ 80% or no gaps between fills exceeding 5 days
If not adherent, deny as not meeting criteria and address adherence with the member.
The member is actively participating in a lifestyle or nutrition support program.
Participation in a lifestyle or nutrition support program is required.
The member has had a positive clinical response to therapy, or the prescriber has submitted documentation of continued medical necessity in accordance with the initial criteria.
If neither is met, deny as not meeting criteria. Positive clinical response or documentation of continued medical necessity is required.

Medications prescribed primarily for weight reduction are not a covered benefit on the Oregon Health Plan, according to the Health Evidence Review Commission (HERC) Prioritized List of Health Services and Guideline Note 5. Coverage may be considered when the member is 20 years of age or younger or has a covered comorbid condition that allows coverage, such as diabetes. If neither circumstance applies, the request does not meet coverage criteria.

Use of pharmacologic therapy is not medically appropriate for children under age 8 per the American Academy of Pediatrics Clinical Practice Guidelines. Requests for members under age 8 should be denied as not meeting criteria or sent for MD review.

Eligibility Thresholds and Definitions

Adult BMI

Adult BMI thresholdGreater than or equal to 30 mg/m2

Eligibility pathwayStandard BMI eligibility applies when the member’s BMI is at least 30 mg/m2.

Authorization decisionWhen the standard BMI threshold is not met, evaluate the lower-BMI cardiovascular risk-factor pathway.

Pediatric BMI

Initial BMI thresholdAt or above the 95th percentile

Applies toMembers under 18 years of age

Percentile basis

Authorization, Documentation, and Denial Risks

Prior Authorization

Initial Authorization

For an initial request, coverage may proceed when the medication is prescribed primarily for weight reduction in a member age 20 or younger, or when the member has a covered comorbid condition (such as diabetes). The member must be age 8 or older, have documented comprehensive intensive behavioral intervention for at least six months, and have the member, parent, or caregiver actively participating in a lifestyle or nutrition support program with attestation.

The medication must be supported by an FDA-approved indication and age-based dosing recommendations or by compendia.
The member must meet the applicable BMI or pediatric BMI-percentile and cardiovascular-risk-factor criteria.
The member must have trialed and failed all appropriate less costly alternative therapies.
When all criteria are met, approve for up to six months.

Prior Authorization

Renewal Authorization

Renewal authorization requires documented adherence, active participation in a lifestyle or nutrition support program, and either a positive clinical response or documentation of continued medical necessity consistent with the initial criteria.

Policy Background

The policy covers pharmacologic treatment for weight management in eligible adult and pediatric members when clinical criteria and nonpharmacologic treatment requirements are met. Before initial approval, the member must have participated in comprehensive, intensive behavioral interventions for at least 6 months, with adequate documentation, and the member, parent, or caregiver must actively participate in a lifestyle or nutrition support program. Pediatric treatment is limited to members age 8 or older; younger children require medical review.

Policy Summary

PayerAdvanced Health

PolicyMedications for Weight Management Drug Use Criteria

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionDocument at least six months of comprehensive, intensive behavioral interventions before initial authorization.

SourceLink

On This Page

Pediatric or Lower Adult BMI Risk Pathway

Lower BMI conditionAdult BMI less than 30 mg/m2, or pediatric initial BMI below the 95th percentile

Risk-factor requirementOne or more cardiovascular disease risk factors must be present

Qualifying risk factorsDiabetes, hypertension, or dyslipidemia

Renewal Adherence

Medication possession ratioMPR greater than or equal to 80%

Prescription-fill gapNo gap between fills may exceed 5 days

If threshold is not metRenewal does not meet criteria; address adherence with the member.

Adherent to Therapy

MPR standardMedication possession ratio greater than or equal to 80%

Fill-gap standardNo gaps between prescription fills exceeding 5 days

DefinitionA member is adherent when either the MPR standard is met or there are no prescription-fill gaps exceeding 5 days.

Adherence is defined as a medication possession ratio (MPR) of at least 80% or no gap between fills exceeding five days.
When renewal criteria are met, approve for up to six months.

Step Therapy

Trial and Failure of Lower-Cost Alternatives

Before initial approval, the member must have trialed and failed all appropriate less costly alternative therapies. If this prerequisite is not met, deny the request and instruct the reviewer to list appropriate less costly alternatives for trial.

Documentation Required

Behavioral Intervention History

Adequate documentation must show that the member has been engaged in comprehensive, intensive behavioral interventions for at least six months. If this history is not documented, deny the request as not meeting criteria.

The six-month intervention requirement applies to initial authorization.

Documentation Required

Lifestyle Program Attestation

The member, parent, or caregiver must be actively participating in a lifestyle or nutrition support program, and an attestation of participation is required for initial authorization.

If participation or the required attestation is absent, deny the request as not meeting criteria.

Documentation Required

BMI and Risk-Factor Documentation

Document the member's age and applicable BMI criteria. The BMI must be at least 30 kg/m², or for a member under 18, the initial BMI must be at or above the 95th percentile for age and sex. If BMI is below 30 kg/m² or below the 95th percentile, coverage requires one or more cardiovascular risk factors: diabetes, hypertension, or dyslipidemia.

If the BMI, percentile, and applicable risk-factor criteria are not met, send the request for physician review of medical appropriateness and necessity.

Documentation Required

Indication and Dosing Support

Document that the medication is prescribed consistently with an FDA-approved indication and age-based dosing recommendations, or that the use is supported by compendia. Unsupported off-label use or dosing is not covered.

If indication, dosing, or compendia support is absent, deny the request because off-label use is not a covered benefit under the Oregon Health Plan.

Documentation Required

Alternative Therapy History

Document the appropriate less costly alternatives reviewed and the member's trial and failure of all applicable alternatives before initial approval.

If the alternatives have not been adequately tried and failed, deny the request and identify the appropriate less costly options.

Documentation Required

Renewal Documentation

For renewal, document adherence, active participation in a lifestyle or nutrition support program, and either a positive clinical response to therapy or continued medical necessity under the initial criteria.

Adherence requires an MPR of at least 80% or no fill gap exceeding five days.
Lifestyle or nutrition support participation must be documented.
The prescriber must document positive clinical response or continued medical necessity.

Denial Risk

Primary Weight-Loss Use Over Age 20

Deny an initial request when the medication is prescribed primarily to reduce weight for a member older than 20. Medications for weight loss are not a covered benefit on the Oregon Health Plan under the HERC Prioritized List of Health Services and Guideline Note 5.

Denial Risk

No Covered Comorbidity

Deny an initial request when the medication is not being prescribed primarily for weight reduction and the member does not have a covered comorbid condition, such as diabetes, that allows coverage.

The denial is based on the Oregon Health Plan coverage limitation for weight-loss medications under the HERC Prioritized List of Health Services and Guideline Note 5.

Denial Risk

Age Under 8

For a member younger than 8, deny the request as not meeting criteria or send it for physician medical review. Pharmacologic treatment is not medically appropriate for children under age 8 according to American Academy of Pediatrics Clinical Practice Guidelines.

Denial Risk

Behavioral or Lifestyle Requirements Not Met

Deny the request when the member has not been engaged in comprehensive, intensive behavioral interventions for at least six months or when the member, parent, or caregiver is not actively participating in a lifestyle or nutrition support program.

Adequate behavioral-intervention documentation is required.
Lifestyle or nutrition support participation and attestation are required.

Denial Risk

Unsupported Off-Label Use

Deny the request when the medication's use or dosing is not supported by an FDA-approved indication and age-based dosing recommendations or by compendia. Off-label use is not a covered benefit under the Oregon Health Plan.

Denial Risk

BMI Criteria Not Met

When the BMI, pediatric BMI percentile, or applicable cardiovascular risk-factor criteria are not met, send the request for physician review of medical appropriateness and necessity rather than approving it automatically.

For members under 18, the initial BMI must be at or above the 95th percentile for age and sex, or a BMI below the 95th percentile must be accompanied by diabetes, hypertension, or dyslipidemia.
For adults, the applicable BMI threshold is at least 30 kg/m².

Denial Risk

Less Costly Alternatives Not Tried

Deny the initial request when the member has not trialed and failed all appropriate less costly alternative therapies. The reviewer should list the appropriate less costly alternatives that must be tried.

Denial Risk

Renewal Criteria Not Met

Deny renewal when any required continuation criterion is not met: adherence, active participation in a lifestyle or nutrition support program, or positive clinical response or documented continued medical necessity.

Address inadequate adherence with the member.
Participation in a lifestyle or nutrition support program is required.
Positive clinical response or documentation of continued medical necessity consistent with the initial criteria is required.