CurrentAnthemPolicy N/A

Prior authorization for weight-loss medications

This form defines prior authorization requirements and clinical criteria for Medicaid members in Virginia requesting coverage of weight-loss medications (including GLP-1 receptor agonists, orlistat, stimulants, Imcivree®, and related agents). It applies to prescribers submitting PA requests for Anthem/HealthKeepers Medicaid products.

Policy Summary

PayerAnthem

PolicyPrior authorization for weight-loss medications

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the prior authorization form with required recent documentation (medical status, individualized weight-loss plan, and accurate height/weight within 60 days).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 moInitial auth length (typical)

BMI ≥30Common BMI threshold

3–6 moTrial durations

Age ≥6Imcivree min age

Coverage and Medical Necessity Criteria

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Initial and renewal medical necessity criteria

Coverage provided when ALL applicable agent-specific criteria and general requirements are met.

General requirements: Absence of medical contraindications; participation in nutritional counseling and physical activity program unless medically contraindicated; commitment to continue the weight-loss treatment plan; provider attests if obesity is disabling/life‑threatening; written documentation of medical status and individualized weight‑loss plan and accurate height/weight from within the last 60 days.

From general coverage and documentation requirements

Agent-specific BMI and age criteria: Phentermine, phendimetrazine (tablet/ER), orlistat, phentermine/topiramate: BMI ≥ 30 kg/m2 OR BMI ≥ 27 kg/m2 with ≥1 weight‑related comorbidity; benzphetamine and diethylpropion (and phentermine/topiramate for certain ages): BMI ≥ 30 kg/m2; Imcivree® (min age 6): BMI ≥ 30 kg/m2 plus genetic confirmation or Bardet‑Biedl syndrome and prescriber specialty requirements; GLP‑1 receptor agonists (Wegovy/Saxenda min age 12, Zepbound min age 18): BMI > 40 kg/m2 if no risk factors OR BMI > 37 kg/m2 with ≥1 risk factor (dyslipidemia, hypertension, or type 2 diabetes).

Minimum ages per FDA approvals; see genetic and GLP‑1 nodes for additional requirements

GLP‑1 specific prerequisites: Member has tried and failed one non‑GLP‑1 weight‑loss medication (accepted drug trial definitions apply) OR is intolerant to all non‑GLP‑1 weight‑loss medications; member is not concurrently on another GLP‑1 receptor agonist; member has tried and failed the selected product per the Preferred Drug List when applicable.

Applies when a GLP‑1 agent is requested; accepted trial durations: GLP‑1 = six months without ≥5% body weight reduction (see definitions)

Imcivree®‑specific requirements: Prescribed by or in consultation with an endocrinologist or geneticist; member has Bardet‑Biedl syndrome OR confirmed POMC, PCSK1, or LEPR deficiency by genetic test; genetic variants must be interpreted as pathogenic, likely pathogenic, or of uncertain significance (VUS).

Applies when Imcivree® is requested (min age 6)

Response criteria for renewals: Agent‑specific response required for renewal: stimulants and certain agents – ≥10‑pound weight loss in initial 3 months to extend; orlistat – ≥10‑pound weight loss to extend; GLP‑1 receptor agonists – ≥5% reduction in body weight compared to the most recent authorization to extend; Imcivree® – ≥5% reduction in body weight (or ≥5% of baseline BMI in those with continued growth potential) to extend. Renewals will not be granted once member reaches BMI < 25. Renewals must be submitted within 30 days of prior authorization expiration.

Renewal thresholds and limits; see authorization lengths for maximum durations and waiting periods

BMI and Related Criteria

BMI thresholds by agent

Adult non‑GLP‑1 agents (e.g., phentermine, phendimetrazine, orlistat, phentermine/topiramate)BMI ≥ 30 kg/m2 OR BMI ≥ 27 kg/m2 with ≥1 weight‑related comorbidity (e.g., coronary heart disease, dyslipidemia, hypertension, sleep apnea, type 2 diabetes)

Younger/alternate formulations (benzphetamine, diethylpropion, phentermine/topiramate ages 12–17)BMI ≥ 30 kg/m2 (minimum ages per FDA approval)

Imcivree® (pediatric)BMI ≥ 30 kg/m2 plus genetic confirmation (Bardet‑Biedl syndrome OR POMC/PCSK1/LEPR deficiency with variants interpreted as pathogenic, likely pathogenic, or VUS); prescriber is/consults endocrinologist or geneticist

GLP‑1 receptor agonists (Wegovy/Saxenda/Zepbound)BMI > 40 kg/m2 if no risk factors; OR BMI > 37 kg/m2 with ≥1 risk factor (dyslipidemia, hypertension, or type 2 diabetes)

Authorization, Documentation, and Submission Requirements

Denial Risk

Incomplete information triggers denial

Incomplete physician-supplied information will result in denial of the request. If the physician does not provide the necessary information, the request will be denied and a fax form requesting additional information will be sent to the prescriber.

If additional information is requested, respond promptly to avoid delays.

Documentation Required

Required recent documentation

Written documentation from within the last 60 days is required and must include medical status and an individualized weight-loss plan (specific reduced-calorie meal plan, recommended routine physical activity, and behavioral intervention). Accurate height and weight measurements within the last 60 days must also be provided.

Medical status and weight-loss plan dated within 60 days
Accurate height and weight within 60 days
Summary/details of prior weight-loss treatment plans (diet and exercise) and a copy of the plan

Prior Authorization

Form completion and submission

All requested form fields must be completed and the prescriber must sign the form. Incomplete forms will delay PA processing. The completed form and any supporting documentation may be faxed to 844-512-7020. Submission of documentation does not guarantee coverage.

Prescriber signature and date required
Include drug name, form, strength, dosing frequency, length of therapy, quantity, day supply

Step Therapy

Prior non-GLP-1 trial required for GLP-1 agents

For GLP-1 receptor agonists indicated for weight loss, the member must have tried and failed one of the non-GLP-1 weight-loss medications (or be intolerant to all non-GLP-1 weight-loss medications) as defined by the accepted drug trials (e.g., three- or six-month trials without required weight loss). Member must not be concurrently on another GLP-1 receptor agonist and must have also tried and failed the selected product if applicable per the Preferred Drug List.

Definition of accepted drug trial: GLP-1 trial = six-month trial without a body weight reduction of 5%
Member intolerant to all non-GLP-1 meds satisfies trial requirement

Clinical and Program Background

The prior authorization form is designed to support clinical assessment and document that required behavioral and medical management components are in place before and during pharmacologic weight-loss therapy. Required elements include documentation of an individualized weight-loss plan (a specific reduced-calorie meal plan, recommended routine physical activity, and behavioral intervention), participation in nutritional counseling and a physical activity program unless contraindicated, commitment to continue the weight-loss plan, and accurate height and weight measurements — all documented within the last 60 days.

OpenPayer

Prior authorization for weight-loss medications

Coverage and Medical Necessity Criteria

BMI and Related Criteria

Authorization, Documentation, and Submission Requirements

Clinical and Program Background

Trial Definitions and Terms