CurrentBlue Cross Blue Shield - IowaPolicy 05.04.33

Drugs for Weight Loss Management (prior authorization policy)

Defines prior authorization criteria, required documentation, approvals, limits, and exclusions for selected prescription weight-loss drugs for Wellmark/Blue Cross Blue Shield - Iowa for plans that allow coverage of weight loss medications.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyDrugs for Weight Loss Management (prior authorization policy)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 19, 2026

Next Review DateN/A

Key ActionSubmit prior authorization with chart notes documenting BMI, comorbidities, participation in a comprehensive weight management program, and drug-specific response data per criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

9named drug products/groups addressed

3max coverage for short-term anorectics (months/year)

≥5%/≥3%typical weight-loss response thresholds for continuation

RequiredBMI and comorbidity evidence for prior authorization

Prior Authorization Criteria by Drug / Indication

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General prior authorization requirements / documentation

Required documentation to support initial and continuation prior authorization requests:

ALL of the following

Chart notes or medical record documentation of Body Mass Index (BMI)
Chart notes or medical record documentation of weight-related comorbid condition, if applicable
Chart notes, medical record documentation, or claims history supporting established cardiovascular disease (e.g., prior myocardial infarction, prior stroke, or symptomatic peripheral arterial disease) and documentation of standard-of-care cardiovascular treatment when applicable (antiplatelet, lipid-lowering, antihypertensive)
Chart notes or medical records documenting clinical findings supporting diagnosis of metabolic dysfunction-associated steatohepatitis (MASH), if applicable

General note: These documentation elements are required for both initial and continuation requests for covered weight loss drugs when prior authorization is applicable to the member's benefit.

I. Benzphetamine, diethylpropion, phendimetrazine, phentermine (short-term anorectics) - Approval criteria

Covered with prior authorization when ALL of the following are met (short-term anorectics limited to 3 months per year):

ALL of the following

Program participation or prior therapy
- Patient has participated in a comprehensive weight management program with behavioral modification, reduced calorie diet and increased physical activity with continuing follow-up for at least 6 months prior to drug therapy
- Patient has participated in such program (duplicative language in policy)
Baseline BMI >= 30 kg/m2>= 30 kg/m2
Baseline BMI >= 27 kg/m2 AND additional risk factors (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia)

II. Contrave (naltrexone HCl/bupropion HCl ER) - Approval and continuation criteria

Covered with prior authorization when any of the following approval or continuation pathways are met. Documentation is required for response; initial approval 3 months, continuation 36 months per policy note.

ANY of the following

ALL of the following
- Patient has completed at least 4 months of therapy with the requested drug
- Patient lost >= 5% of baseline body weight OR has continued to maintain initial 5% weight loss
  Documentation required
- Patient is currently on and will continue reduced calorie diet, increased physical activity, and behavioral modifications
- Requested drug will NOT be used in combination with another targeted weight loss agent for the requested indication

III. Qsymia (phentermine/topiramate ER) - Approval criteria

Covered with prior authorization when ALL of the following are met, including baseline BMI options, combination restrictions, dosing/titration, and response-based continuation rules.

ALL of the following

ANY of the following
- Baseline BMI >= 30 kg/m2
- Baseline BMI >= 27 kg/m2 AND additional risk factors (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia)
Requested drug will not be used in combination with another targeted weight loss agent for the requested indication
If request is for phentermine, it will not be used in a patient also using Fintepla (fenfluramine)

IV. Saxenda (liraglutide injection) - Approval criteria

Covered with prior authorization when adult or pediatric criteria and response thresholds are met; include documentation requirements and approval durations.

ANY of the following

ALL of the following
- Patient is >=18 years old
- Patient has completed at least 16 weeks of therapy with the requested drug
- Patient lost >=5% of baseline body weight OR continued to maintain initial 5% weight loss
  Documentation required
- Patient will continue reduced calorie diet, increased physical activity and behavioral modifications

V. Wegovy (semaglutide injection, Wegovy HD, Wegovy tablet) - Approval criteria for adults

Covered with prior authorization when any of the adult Wegovy pathways, program participation, response, or cardiovascular indication criteria are met. Initial approval 6 months; continuation 12 months.

ANY of the following

ALL of the following
- Patient participated in a comprehensive weight management program with behavioral modification, reduced calorie diet, increased physical activity, and continuing follow-up for at least 6 months prior to therapy
- ANY of the following
  - Baseline BMI >= 30 kg/m2
  - Baseline BMI >= 27 kg/m2 AND additional risk factors (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia)

VI. Wegovy (semaglutide injection) - Pediatric (12-17 years) criteria

Covered with prior authorization when pediatric-specific BMI percentile, program participation, or response criteria are met. Initial approval 6 months; continuation 12 months per policy.

ANY of the following

ALL of the following
- Member is 12 to 17 years of age
- Completed at least 3 months of therapy with the requested drug at a stable maintenance dose
- Member has at least 5% reduction in BMI from baseline OR has continued to maintain initial 5% reduction in BMI
  Documentation required
- Member will continue reduced calorie diet, increased physical activity, and behavioral modifications

VII. Wegovy for MASH (noncirrhotic metabolic dysfunction-associated steatohepatitis) - Approval criteria

Covered with prior authorization when ALL the following MASH diagnostic, specialist, exclusion, and lifestyle criteria are met. Initial and continuation approvals are 12 months.

ALL of the following

Diagnostic methods (one required)
- Liver biopsy confirming MASH with moderate to advanced fibrosis (F2-F3)
- FAST score (FibroScan-AST)
- MAST (MRI-PDFF, MRE, and AST)
- MEFIB (MRE combined with FIB-4 index)

VIII. Xenical (orlistat) - Approval criteria

Covered with prior authorization when either response-based continuation or program participation / BMI criteria are met. Initial approval 12 months.

ANY of the following

ALL of the following
- Patient has completed at least 6 months of therapy with the requested drug
- Patient lost >=5% of baseline body weight OR has continued to maintain initial 5% weight loss
  Documentation required
- Patient will continue reduced calorie diet, increased physical activity and behavioral modifications
- Requested drug will NOT be used in combination with another targeted weight loss agent for the requested indication

IX. Zepbound (tirzepatide injection) - Approval criteria

Covered with prior authorization when the patient is an adult and meets general policy criteria; the single explicit age requirement below is required for Zepbound requests.

ALL of the following

Patient is 18 years of age or older
General BMI, comorbidity, program participation, and response criteria elsewhere in this policy apply to Zepbound requests (e.g., participation in a comprehensive weight management program and renewal response thresholds).
Operational note
Initial approval typically 6 months; renewal requires documented >=5% weight loss at 6 months as described in other policy sections.
Approval durations

Special note: Requests not meeting other policy criteria (BMI, program participation, response thresholds) will be considered not medically necessary.

Exclusions and not medically necessary conditions

Drugs are considered not medically necessary when criteria are not met or for specified excluded indications.

ALL of the following

Requests for Wegovy or Zepbound for patients with type 2 diabetes mellitus as a comorbid, weight-related condition are excluded; resubmit request for a GLP-1 receptor agonist or GIP-GLP-1 receptor agonist that is FDA-approved for type 2 diabetes mellitus.
Drugs are considered not medically necessary for patients who do not meet the criteria set forth in this policy.
Members currently receiving medication as samples or via manufacturer's patient assistance program must meet initial approval criteria to continue coverage.

Qsymia — initiation and continuation criteria

Qsymia initiation requires specified titration; continuation and renewal depend on dose-specific response at 12-week evaluation points. Initial approval duration is 3 months.

ALL of the following

- Start Qsymia 3.75 mg/23 mg once daily for 14 days, then increase to 7.5 mg/46 mg
- If inadequate response on 7.5 mg/46 mg at 12 weeks (less than 3% weight loss), discontinue or escalate to 11.25 mg/69 mg for 14 days then 15 mg/92 mg maintenance
- For renewal after 12 weeks on 7.5 mg/46 mg: patient must have lost >=3% of baseline body weight or maintained initial 3% weight loss
- For renewal after 12 weeks on 15 mg/92 mg: patient must have lost >=5% of baseline body weight or maintained initial 5% weight loss

Saxenda — initiation and continuation criteria (adult and pediatric)

Saxenda initiation and continuation criteria differ for adults and pediatrics. Evaluate response at defined timepoints and discontinue if thresholds not met.

ALL of the following

Indication: adjunct to reduced-calorie diet and increased physical activity for adults with BMI >=30 kg/m2 or BMI >=27 kg/m2 with comorbidity; pediatric patients age >=12 years with body weight >60 kg and BMI corresponding to adult BMI >=30 by Cole Criteria
Evaluation and discontinuation criteria
- Assess at 16 weeks after initiation; discontinue if <4% weight loss. For renewal after 16 weeks: must have lost >=5% baseline weight or maintained initial 5% weight loss. Initial approval duration for adults new to therapy is 6 months.
  Adult evaluation
- Assess BMI after 12 weeks on maintenance dose; discontinue if <1% BMI reduction. For pediatric renewal after 20 weeks: must have >=1% reduction in BMI from baseline or maintained initial 1% reduction. Initial approval duration for pediatric new to therapy is 6 months; dose escalation to maintenance may take up to 8 weeks.

Wegovy — initiation and continuation criteria

Wegovy requires participation in a comprehensive weight management program prior to initiation; initial approval 6 months for dose escalation/maintenance and renewal requires documented ≥5% weight loss at 6 months.

ALL of the following

Requirement: participation in a comprehensive weight management program with behavioral modification, reduced calorie diet, increased physical activity, and continuing follow-up for at least 6 months prior to initiating drug therapy
Initial approval duration: 6 months to allow dose escalation to maintenance dosage and to confirm maintenance therapy
For renewal after 6 months: patient must have lost >=5% of baseline body weight or maintained initial 5% weight loss; discontinue if not met
Renewal criteria
Coadministration with other semaglutide-containing products or other GLP-1 receptor agonists is not recommended.
Coadministration caution

Zepbound — initiation and continuation criteria

Zepbound requires participation in a comprehensive weight management program prior to initiation; initial approval 6 months and renewal requires ≥5% weight loss at 6 months.

ALL of the following

Requirement: participation in a comprehensive weight management program with behavioral modification, reduced calorie diet, increased physical activity, and continuing follow-up for at least 6 months prior to initiating drug therapy
Initial approval duration: 6 months to allow dose escalation and maintenance therapy
For renewal after 6 months: patient must have lost >=5% of baseline body weight or maintained initial 5% weight loss; discontinue if not met
Renewal criteria
Coadministration with other tirzepatide-containing products or any GLP-1 receptor agonist is not recommended.
Coadministration caution

Xenical (orlistat) — initiation and continuation criteria

Orlistat (Xenical) is indicated as an adjunct to diet; initial approval 12 months and renewal requires weight-loss response after at least 6 months.

ALL of the following

Patient eligibility: BMI >=30 kg/m2 OR BMI >=27 kg/m2 with risk factors (e.g., hypertension, dyslipidemia)
Initial approval: 12 months
For renewal after at least 6 months of therapy, patient must have lost >=5% of baseline body weight or maintained initial 5% weight loss. Documentation required.
Renewal criteria
Patient is currently on and will continue reduced calorie diet, increased physical activity, and behavioral modifications

Drugs and Policy Identifiers (listed product strengths / supply)

Drugs / product descriptions and strength/days supply (listed in policy)NDC-like/formulation

Contrave	naltrexone HCl and bupropion HCl - multiple tablet counts and day supply configurations listed (e.g., 30 days, 180 tabs, various strengths)
Phendimetrazine Tartrate	multiple strengths and counts (e.g., 25 mg, ER 24 HR cap 105 mg, 30 days/180 tabs options listed)
Phentermine	multiple strengths and forms (30 mg, 37.5 mg caps/tabs; 30-day supply examples)
Qsymia	phentermine/topiramate ER strengths listed (7.5/46 mg, 11.25/69 mg, 15/92 mg), 30-day supplies
Saxenda	liraglutide pen-injection 18 mg/3 mL; 5 pens = 30 days listed
Wegovy injection	semaglutide injection all strengths; 4 pens = 28 days listed
Wegovy tablet	semaglutide tablet (oral) - strengths referenced generically
Xenical	orlistat 120 mg caps; 30-day supply (30 tabs) listed
Zepbound	tirzepatide injection all strengths; 4 pens = 28 days listed

Policy identifiermixed

05.04.33

Policy number as listed in Policy History

What Providers Must Do

Prior Authorization

Prior authorization required

Prior authorization review is required for covered weight‑loss medications for plans that include coverage. Submit chart notes/medical records documenting Body Mass Index (BMI), weight‑related comorbidities if applicable, prior participation in a comprehensive weight management program, and drug‑specific response evidence as specified in the policy for the requested agent.

Documentation Required

Required documentation elements

Provide chart notes or medical record documentation of: BMI, any weight‑related comorbid conditions when applicable, evidence of participation in a comprehensive weight management program, and for cardiovascular indications documentation of established cardiovascular disease and standard‑of‑care cardiovascular medications or documented reasons these cannot be used.

Body Mass Index (BMI) documentation
Documentation of weight‑related comorbid condition (if applicable)
Evidence of participation in a comprehensive weight management program (behavioral modification, reduced‑calorie diet, increased physical activity)
For CV indications: documentation of established CV disease (previous MI, stroke, or symptomatic PAD) and current/justified nonuse of antiplatelet, lipid‑lowering, or antihypertensive therapies

Prior Authorization

Response documentation for continuation

For continuation/renewal requests, document medication‑specific weight‑loss response at the policy evaluation timepoints (see drug thresholds). Examples: Contrave—≥5% weight loss after 4 months; Saxenda—adults ≥5% at 16 weeks; Wegovy/Zepbound/Xenical—≥5% at 6 months; Qsymia—dose‑specific 3% or 5% thresholds at 12 weeks.

Contrave: documentation of ≥5% baseline weight loss after ≥4 months for renewal
Saxenda (adult): documentation of ≥5% baseline weight loss after 16 weeks for renewal
Wegovy and Zepbound: documentation of ≥5% baseline weight loss after 6 months for renewal
Xenical: documentation of ≥5% baseline weight loss after ≥6 months for renewal
Qsymia: documentation of ≥3% at 12 weeks on 7.5/46 mg or ≥5% at 12 weeks on 15/92 mg (dose‑specific)

Denial Risk

Denial risk for excluded indications

Requests will be denied or considered not medically necessary when the policy exclusions or required criteria are not met. Specifically, requests for Wegovy or Zepbound for patients with type 2 diabetes as the weight‑related comorbid condition are excluded — such requests should be resubmitted for an agent FDA‑approved for type 2 diabetes.

General denial risk if prior authorization criteria (BMI, program participation, response thresholds) are not met
Wegovy and Zepbound are excluded for requests where type 2 diabetes is the comorbid indication; resubmit for a GLP‑1 or GIP‑GLP‑1 agent FDA‑approved for diabetes

Documentation Required

Specialist involvement for MASH

For Wegovy prescribed for MASH, the request must include diagnostic confirmation of moderate‑to‑advanced fibrosis and the medication must be prescribed by or in consultation with an appropriate specialist (gastroenterologist, hepatologist, cardiometabolic specialist) or a PCP in consultation with one of these specialists.

Diagnostic confirmation: liver biopsy or validated noninvasive testing consistent with F2–F3 fibrosis (FAST, MAST, MEFIB)
Prescriber requirement: prescribed by or in consultation with gastroenterologist, hepatologist, cardiometabolic specialist, or PCP in consultation with these specialists

Documentation Required

Weight-loss response documentation

Document baseline body weight and BMI and report percent weight change at the medication‑specific evaluation timepoint to support continuation (examples: 12–16 weeks for Qsymia/Saxenda evaluation; 6 months for Wegovy/Zepbound/Xenical).

Record baseline weight and BMI at initiation
Report percent weight change at the agent’s specified evaluation point (e.g., Qsymia 12 weeks, Saxenda 16 weeks, Wegovy/Zepbound/Xenical 6 months)
Include supporting chart notes or measurements in the medical record for renewal requests

Prior Authorization

Initial approval durations and renewal basis

Obtain prior authorization consistent with the policy’s initial approval durations and base renewals on required response documentation. Typical initial approval periods include: Qsymia — 3 months; Saxenda (adults) — 6 months; Wegovy and Zepbound — 6 months; Xenical — 12 months. Submit evidence of the required percent weight loss or maintenance for renewal.

Qsymia initial approval: 3 months (90 days) per year for short‑term or dose escalation scenarios
Saxenda adult initial approval: 6 months; renewal requires response at 16 weeks
Wegovy and Zepbound initial approval: 6 months to allow escalation to maintenance; renewal after 6 months requires ≥5% weight loss
Xenical initial approval: 12 months; renewal after ≥6 months requires ≥5% weight loss

Denial Risk

Failure to meet response thresholds

If the patient fails to meet the policy‑specified percent weight‑loss thresholds at the defined evaluation points, therapy should be discontinued and will not be renewed per policy (e.g., Qsymia, Saxenda, Wegovy, Zepbound, Xenical continuation rules).

Policy directs discontinuation when dose‑ or time‑specific goals are not met (e.g., Qsymia <3% at 12 weeks on 7.5/46 mg or <5% at 12 weeks on 15/92 mg; Saxenda <4% at 16 weeks for adults)
Failure to meet thresholds makes continued approval unlikely and renewal will be denied

Documentation Required

Program participation requirement (Wegovy, Zepbound)

Before initiating Wegovy or Zepbound, confirm and document participation in a comprehensive weight management program with behavioral modification, reduced‑calorie diet, increased physical activity, and at least 6 months of prior follow‑up.

Document participation in a comprehensive program with at least 6 months of continuing follow‑up prior to drug initiation
Include program description and dates in chart notes to support prior authorization

Numeric Thresholds and Defined Terms

Key thresholds and limits from policy

BMI for adult eligibility≥ 30 kg/m2 or ≥ 27 kg/m2 with additional risk factors (hypertension, type 2 diabetes, dyslipidemia)

Short-term anorectics duration limitMaximum 3 months per year per agent (benzphetamine, diethylpropion, phendimetrazine, phentermine)

Contrave response for continuation≥ 5% weight loss after 4 months (documentation required)

Qsymia response for continuationDose-specific: ≥3% at 12 weeks on 7.5 mg/46 mg or ≥5% at 12 weeks on 15 mg/92 mg; titration and escalation rules apply (evaluate at 12 weeks)

Saxenda response thresholdsAdults: evaluate at 16 weeks — discontinue if <4%; renewal requires ≥5% weight loss at 16 weeks. Pediatrics (12–17): ≥1% BMI reduction on maintenance dose after 12 weeks (documentation required)

Wegovy adult and MASH requirementsAdults: ≥5% weight loss after 3–6 months at stable maintenance dose for continuation; for MASH: moderate to advanced fibrosis (F2–F3) confirmed by liver biopsy or validated noninvasive testing (FAST, MAST, MEFIB)

Diabetes exclusion for Wegovy CV indicationNo diagnosis of diabetes mellitus or pancreatitis within 180 days prior to request (for CV risk reduction indication)

Definitions used in prior authorization criteria

Comprehensive weight management programProgram that encourages behavioral modification, reduced calorie diet, increased physical activity with continuing follow-up (policy uses a 6-month participation benchmark in many criteria)

Established cardiovascular disease (per policy)Previous myocardial infarction, previous stroke, or symptomatic peripheral arterial disease (e.g., intermittent claudication with ABI <0.85 at rest), peripheral arterial revascularization, or amputation due to atherosclerotic cardiovascular disease

MASHMetabolic dysfunction-associated steatohepatitis (formerly NASH) with moderate to advanced liver fibrosis (consistent with stages F2–F3)

Validated noninvasive fibrosis tests (examples)FAST (FibroScan‑AST), MAST (MRI‑PDFF + MRE + AST), MEFIB (MRE + FIB‑4 index) — acceptable alternatives to biopsy for MASH fibrosis staging per policy

Cole CriteriaInternational Obesity Task Force BMI cut-offs by sex and age used to map pediatric BMI to adult BMI equivalents (used to determine pediatric eligibility corresponding to adult BMI ≥30 kg/m2)

Clinical and Policy Rationale

This policy aligns coverage decisions with FDA-approved labeling, clinical practice guidelines, and evidence-based standards to guide prior authorization for select weight-loss medications when the member's benefit permits coverage. It emphasizes that these agents are intended as adjuncts to a reduced-calorie diet, increased physical activity, and behavioral modification, and should be used as part of a comprehensive weight management program rather than as standalone therapy (see FDA labeling and guideline rationale).

The policy applies FDA indications and guideline-based response thresholds to initial and continuation approvals—using BMI eligibility cutoffs of ≥ 30 kg/m2 or ≥ 27 kg/m2 with at least one weight-related comorbidity—and requires documentation of program participation, baseline BMI, and percent weight change at specified evaluation timepoints to continue therapy.

Short-term sympathomimetic anorectics (benzphetamine, diethylpropion, phendimetrazine, phentermine) have narrow FDA labeling for brief use; because long-term safety beyond approximately 12 weeks is not established, the policy limits coverage of each short-term anorectic to a maximum of 3 months (approximately 12 weeks) per 365 days.

Providers requesting prior authorization must submit chart notes or medical records documenting BMI and relevant comorbidities, evidence of participation in a comprehensive weight management program with continuing follow-up, and drug-specific response measures at the required evaluation points to support initial or continued coverage.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyDrugs for Weight Loss Management (prior authorization policy)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 19, 2026

Next Review DateN/A

Key ActionSubmit prior authorization with chart notes documenting BMI, comorbidities, participation in a comprehensive weight management program, and drug-specific response data per criteria.

SourceLink

On This Page

Patient is currently on and will continue a reduced calorie diet, increased physical activity, and behavioral modifications

Requested agent will NOT be used in combination with another targeted weight loss agent for the requested indication

Limit: Maximum 3 months of therapy with the requested short-term anorectic within the past 365 days (per policy)

ALL of the following

Patient has completed at least 12 weeks of Qsymia 15 mg/92 mg therapy
Patient lost >= 5% of baseline body weight (adults) or >= 5% reduction of baseline BMI (pediatrics)
Documentation required
Patient is currently on and will continue reduced calorie diet, increased physical activity, and behavioral modifications
Requested drug will NOT be used in combination with another targeted weight loss agent for the requested indication

ALL of the following

Patient has completed at least 12 weeks of Qsymia 7.5 mg/46 mg therapy AND has not completed at least 12 weeks of therapy with Qsymia 7.5 or 15 mg/92 mg
Patient has participated in a comprehensive weight management program for at least 6 months prior to using drug therapy
Patient is 18 years of age or older
Baseline BMI >= 30 kg/m2 OR baseline BMI >= 27 kg/m2 with at least one weight-related comorbidity

ALL of the following

Patient has continued to maintain their initial 5% weight loss (adults) or initial >=5% BMI reduction (pediatrics)
Patient is currently on and will continue reduced calorie diet, increased physical activity, and behavioral modifications
Requested drug will NOT be used in combination with another targeted agent

ALL of the following

Patient lost at least 3% of baseline body weight (adults) or >=3% BMI reduction (pediatrics)
Patient is currently on and will continue reduced calorie diet, increased physical activity, and behavioral modifications
Requested drug will NOT be used in combination with another targeted agent

ALL of the following

Patient has not lost >=3% (adults) or not experienced >=3% BMI reduction (pediatrics) OR has not continued to maintain initial 3% weight loss
Patient's dose has been escalated to Qsymia 11.25 mg/69 mg and will follow appropriate dose escalation schedule
Documentation required
Patient is currently on and will continue reduced calorie diet, increased physical activity, and behavioral modifications
Requested drug will NOT be used in combination with another targeted agent

Approval durations

Initial approval: 3 months (90 days)
Continuation approval: 36 months

Start Qsymia 3.75 mg/23 mg once daily for 14 days, then increase to 7.5 mg/46 mg

Evaluate at 12 weeks on 7.5 mg/46 mg; if <3% weight loss, discontinue or escalate to 11.25 mg/69 mg for 14 days then 15 mg/92 mg maintenance

Evaluate after 12 weeks on 15 mg/92 mg; if <5% weight loss, discontinue

For renewal after 12 weeks on 7.5 mg/46 mg: >=3% baseline weight loss or maintained initial 3%
For renewal after 12 weeks on 15 mg/92 mg: >=5% baseline weight loss or maintained initial 5%

Initial approval: 3 months
Continuation approval duration: 36 months

Dose escalation operational note: Qsymia 3.75 mg/23 mg and 11.25 mg/69 mg are for titration only; documentation required when dose escalated.

Requested drug will NOT be used in combination with another targeted weight loss agent for the requested indication

ALL of the following

Patient is 12 to 17 years of age
Patient has completed at least 12 weeks of therapy on the maintenance dose of the requested drug
Patient has at least 1% reduction in BMI from baseline OR continued to maintain initial 1% reduction
Documentation required
Patient will continue reduced calorie diet, increased physical activity and behavioral modifications
Requested drug will NOT be used in combination with another targeted weight loss agent for the requested indication

ALL of the following

Patient has participated in a comprehensive weight management program with continuing follow-up for >=6 months prior to drug therapy
Patient has an initial body weight above 60 kg AND BMI corresponding to >=30 kg/m2 by Cole criteria (pediatrics)
Patient will continue reduced calorie diet, increased physical activity and behavioral modifications
Requested drug will NOT be used in combination with another targeted weight loss agent for the requested indication

Approval durations

Initial approval: 6 months (adults and pediatric initial)
Continuation: 12 months

Patient is currently on and will continue reduced calorie diet, increased physical activity and behavioral modifications

Requested drug will NOT be used in combination with another targeted weight loss agent for the requested indication

ALL of the following

Patient is >=18 years old
Patient completed at least 3 months of therapy with the requested drug at a stable maintenance dose
Patient lost >=5% of baseline body weight OR has continued to maintain initial 5% weight loss
Documentation required
Patient will continue reduced calorie diet, increased physical activity and behavioral modifications
Requested drug will NOT be used in combination with another targeted weight loss agent for the requested indication

ALL of the following

ANY of the following
- Baseline BMI >= 30 kg/m2
- Baseline BMI >= 27 kg/m2 AND one of: at least one weight-related comorbid condition (e.g., hypertension or dyslipidemia); established cardiovascular disease documented (previous MI, previous stroke, or symptomatic PAD)
If therapy is for CV risk reduction: patient must be receiving and will continue standard-of-care CV treatment including antiplatelet, lipid-lowering, and antihypertensive drugs unless intolerance/contraindication documented
Patient does not have a diagnosis of diabetes mellitus or pancreatitis within 180 days prior to the request

Approval durations and renewal

Initial approval: 6 months to allow dose escalation to maintenance
Renewal criteria after 6 months: patient must have lost >=5% of baseline body weight or maintained initial 5% weight loss; continuation approval: 12 months

Requested drug will NOT be used in combination with another targeted weight loss agent for the requested indication

ALL of the following

Member participated in a comprehensive weight management program with >=6 months follow-up prior to therapy
Member has an initial BMI at the 95th percentile or greater standardized for age and sex
Member will continue reduced calorie diet, increased physical activity, and behavioral modifications
Requested drug will NOT be used in combination with another targeted weight loss agent for the requested indication

Approval durations

Initial approval: 6 months
Continuation approval: 12 months

Requested medication is prescribed by or in consultation with a gastroenterologist, hepatologist, cardiometabolic specialist or primary care physician in consultation with any of these specialists

ANY of the following

Member is requesting continuation and has achieved or maintained positive clinical response to drug (e.g., improvement in ALT, reduction of liver fat by imaging such as MRI-PDFF or FibroScan CAP)
Member is initial request meeting diagnostic criteria above

Member does not have evidence of cirrhosis, hepatic decompensation or hepatocellular carcinoma

Requested medication will be used in conjunction with healthy lifestyle modifications (diet, exercise, behavioral support)

Approval duration

Initial approval: 12 months
Continuation approval: 12 months

ALL of the following

Patient participated in a comprehensive weight management program with >=6 months follow-up prior to drug therapy
ANY of the following
- Baseline BMI >= 30 kg/m2
- Baseline BMI >= 27 kg/m2 AND additional risk factors (e.g., hypertension, type 2 diabetes mellitus or dyslipidemia)
Patient will continue reduced calorie diet, increased physical activity and behavioral modifications
Requested drug will NOT be used in combination with another targeted weight loss agent for the requested indication

Approval duration

Initial approval: 12 months
Continuation approval: 12 months

Renewal condition: For renewal after at least 6 months of therapy, patient must have lost >=5% of baseline body weight or maintained initial 5% weight loss.

If patient fails to meet specified goals at 12-week evaluation, discontinue therapy; initial approval duration for new therapy or escalation to 11.25 mg/69 mg is 3 months.

Operational note: Qsymia 3.75 mg/23 mg and 11.25 mg/69 mg are for titration only; documentation required when dose-escalated.

Pediatric evaluation

Do not coadminister with other liraglutide-containing products or other GLP-1 RAs; safety in pediatric type 2 diabetes not established.

Coadministration caution

Documentation

Documentation required of percent weight or BMI change at the policy-specified evaluation timepoints to support continuation/renewal.

Clinical note: If therapy is for cardiovascular risk reduction, follow CV-specific requirements including documentation of established cardiovascular disease and standard-of-care CV medications, and ensure no diagnosis of diabetes mellitus or pancreatitis within 180 days prior to request.

Documentation: Document percent weight change at 6 months to support renewal.

Requested drug will NOT be used in combination with another targeted weight loss agent for the requested indication

Clinical note: Long-term use may be considered for patients demonstrating continued weight loss or maintenance.

OpenPayer

Drugs for Weight Loss Management (prior authorization policy)

Prior Authorization Criteria by Drug / Indication

Drugs and Policy Identifiers (listed product strengths / supply)

What Providers Must Do

Numeric Thresholds and Defined Terms

Clinical and Policy Rationale

Policy Updates