CurrentCignaPolicy IP0420

Appetite Suppressants and Orlistat

Cigna prescription benefit prior authorization policy for appetite suppressant medications (benzphetamine, diethylpropion, phendimetrazine, phentermine hydrochloride including Lomaira/Adipex-P, phentermine/topiramate extended-release [Qsymia/generic], Contrave, and orlistat 120 mg [Xenical/authorized generic]). Defines FDA-aligned initial and continuation approval criteria, durations, pediatric indications where applicable, product-specific employer-plan exceptions, exclusions, and required concomitant lifestyle therapy.

Policy Summary

PayerCigna

PolicyAppetite Suppressants and Orlistat

Policy CodePolicy IP0420

Change TypeAnnual revision (criteria, durations, baseline clarifications, product list updates)

Effective DateAug 1, 2025

Next Review Date

Key ActionPrior authorization is required and providers must document baseline BMI and behavioral modification/diet trial and, for continuation, ≥5% weight loss or BMI reduction as specified.

SourceLink

POLICY UPDATE CHANGES

Policy name changed to 'Weight Loss - Other Appetite Suppressants and Orlistat' and later to 'Weight Loss - Appetite Suppressants and Orlistat'.

Phentermine hydrochloride initial therapy duration updated to 3 months (from 4 months); continuing therapy weight loss requirement updated to ≥5% and notes about baseline and incomplete initial therapy added.

Contrave continuing therapy weight loss requirement updated to ≥5% and note added about incomplete initial therapy.

Qsymia initial adult therapy duration updated to 6 months (from 4 months); pediatric initial therapy duration updated to 6 months; continuing therapy weight loss threshold updated to ≥5% and baseline clarifications added; pediatric BMI/BMI-percentile requirements modified/removed per revision.

Orlistat 120 mg initial adult therapy updated to 3 months; continuing therapy weight-loss requirement changed to ≥5%; pediatric initial therapy updated to 3 months; removal of some pediatric percentile requirements.

Policy removed coverage for treatment of hyperlipidemia in non-obese individuals, binge-eating disorder in non-obese individuals, and prevention of diabetes in individuals with BMI < 30 (or <27 with risk factors) from 'Conditions Not Covered'.

Behavioral modification/diet language changed to state the medication will be used concomitantly with behavioral modification and a reduced-calorie diet.

Expanded and standardized comorbidity list for BMI ≥27 kg/m2 and baseline criteria revised to require 'at baseline' language.

Requirement that patient failed to achieve desired weight loss after behavioral modification was removed for adults and pediatrics.

Clarified that concomitant use with other medications FDA-approved for weight loss is not recommended for approval (previously did not specify 'FDA-approved').

Notes clarifying that 'baseline' refers to baseline prior to orlistat 120 mg (Xenical, authorized generic) were added to multiple criteria.

Phentermine/topiramate extended-release (generic to Qsymia) and Lomaira (phentermine) entries were added to the policy (selected revisions referenced).

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7Medications listed

≥5%Continuation weight-loss threshold

3-6mInitial approval durations (varies)

1yContinuing approval duration

3Therapy categories modified

1Conditions not recommended (concomitant FDA-approved agents)

Coverage Summary

Coverage stance: Covered with criteria per Cigna policy IP0420 (effective 08/01/2025, last reviewed 04/15/2025). Scope: prescription benefit prior authorization applies to appetite suppressants and orlistat (phentermine products including Adipex-P/Lomaira/generics, phentermine/topiramate ER [Qsymia/generic], Contrave, and orlistat 120 mg [Xenical/authorized generic]). The agents are approved when FDA- and guideline-aligned initial therapy criteria are met (typically a documented trial of behavioral modification/diet for ≥ 3 months and baseline BMI thresholds) and may be authorized for initial durations of 3–6 months depending on product (phentermine and orlistat: 3 months; Qsymia: 6 months; Contrave: 4 months per criteria). Continuing therapy approvals require documented response (generally ≥ 5% weight/BMI reduction from baseline) and are approved for up to 1 year. Criteria apply to adults and where specified to pediatric patients (e.g., Qsymia and orlistat pediatric indications ≥ 12 years), and baseline BMI references denote values at baseline prior to the requested medication.

Key thresholds & quick facts

Adult BMI thresholds≥ 30 kg/m2 OR ≥ 27 kg/m2 with at least one specified weight-related comorbidity (at baseline)

Pediatric BMI threshold≥ 95th percentile for age and sex (at baseline)

Continuation weight‑loss threshold≥ 5% of baseline body weight

Initial approval duration (range)3–6 months depending on product (most adults: 3–6 months per drug-specific criteria)

Continuation approval duration1 year

Medications listed count7 (appetite suppressants and orlistat listed in policy)

Initial Therapy Criteria

A) Initial Therapy (phentermine hydrochloride)

Covered when ALL of the following are met:

ALL of the following

Patient meets the age requirement for the product (see product-specific nodes below).
Age requirement preserved per product labeling.
Baseline body mass index (BMI) and comorbidity criteria as specified for each product (see product-specific nodes).
Documentation of a comprehensive weight management plan including behavioral modification (dietary counseling, exercise plan, or structured behavioral program).
Behavioral modification must be concurrent with pharmacotherapy; see product-specific requirement for duration prior to approval where applicable.
Preferred product criteria

Continuation Therapy Criteria

Phentermine hydrochloride - Continuing Therapy

Approve when ONE of the following (Initial Therapy or Continuing Therapy) criteria are met:

B) Continuing Therapy (approve for 1 year)

Patient is ≥ 16 years of age
ANY of the following
- At baseline, patient had a BMI ≥ 30 kg/m2
- At baseline, patient had a BMI ≥ 27 kg/m2 AND at baseline had, or currently has, at least ONE weight-related comorbidity (hypertension; type 2 diabetes; dyslipidemia; obstructive sleep apnea; cardiovascular disease; knee osteoarthritis; asthma; chronic obstructive pulmonary disease; metabolic-dysfunction associated steatotic liver disease/non-alcoholic fatty liver disease; polycystic ovarian syndrome; or coronary artery disease)

Pediatric Criteria

Qsymia - Pediatric Initial and Continuing Therapy

Approve when ONE of the following Adult or Pediatric criteria are met:

Top

Orlistat - Pediatric Initial and Continuing Therapy

Approve when ONE of the following Adult or Pediatric criteria are met:

Top

Unproven / Not Recommended Uses

Conditions Not Recommended for Approval

Not recommended when following condition is present:

Concomitant use with other medications FDA-approved for weight loss

Clarified to specify 'FDA-approved' medications; examples updated to reflect product availability. Use of agents for other non-covered indications (e.g., Alli OTC) is not recommended.

Applicable Codes

Drugs referenced in policymixed

Adipex-P	phentermine hydrochloride (brand) - brand criteria: tried generic bioequivalent and cannot take due to inactive ingredients
phentermine (generic)	phentermine hydrochloride generic products
Lomaira	phentermine hydrochloride tablet - employer plan criteria: patient tried generic or inability to use tablets
Qsymia	phentermine/topiramate extended-release (brand and generic)
Contrave	naltrexone HCl/bupropion HCl extended-release tablets
Xenical	orlistat 120 mg capsules (authorized generic)
Alli	orlistat 60 mg OTC - prior authorization and coverage not recommended

Policy Identifiermixed

IP0420

Coverage Policy Number

Provider Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for prescription coverage of appetite suppressants and orlistat products. Affected medication groups include benzphetamine, diethylpropion, phendimetrazine, phentermine products (including Adipex‑P and Lomaira), phentermine/topiramate products (Qsymia and generics), Contrave, and orlistat 120 mg.

Affected medication groups: benzphetamine, diethylpropion, phendimetrazine, phentermine products, Qsymia/generic (phentermine/topiramate extended‑release), Contrave (naltrexone/bupropion), orlistat 120 mg

Documentation Required

Baseline BMI and Weight Documentation

Document the patient’s baseline BMI and baseline weight in the medical record prior to initiating therapy. Include date of measurement and the numeric BMI value.

Documentation Required

Clinical Evidence & Guidelines

Evidence and guideline context: Major society guidance (Endocrine Society 2015, AACE/ACE 2016, AGA 2022, and AAP pediatric guidance) support using pharmacotherapy as an adjunct to lifestyle modification for adults (and for adolescents ≥ 12 years per pediatric guidance) who meet BMI and comorbidity thresholds. These guidelines recommend pharmacologic agents be added to behavioral interventions for selected patients with BMI ≥ 30 kg/m2 or ≥ 27 kg/m2 with weight-related comorbidities and endorse evaluating response (commonly a ≥ 5% weight loss) to guide continuation.

Guideline alignment (quick reference)

Endocrine Society (2015)Recommends pharmacotherapy as adjunct to behavioral modification for patients with BMI ≥ 30 or ≥ 27 with comorbidity; continue if weight loss ≥ 5% at 3 months

AGA (2022)Recommends adding pharmacological agents for adults with inadequate response to lifestyle interventions; lists Qsymia, Contrave, phentermine among options

Background

Background: FDA indications vary across appetite suppressants. Many agents are indicated as adjuncts to a reduced-calorie diet and increased physical activity for adults meeting BMI thresholds (≥ 30 kg/m2 or ≥ 27 kg/m2 with specified comorbidities). Some products have pediatric labeling (phentermine/topiramate extended-release [Qsymia/generic] and orlistat 120 mg are indicated for patients ≥ 12 years). Product examples include phentermine formulations (Adipex-P, Lomaira, generics), phentermine/topiramate ER (Qsymia/generic), Contrave, and orlistat 120 mg (Xenical/authorized generic). The policy aligns coverage criteria to FDA indications and guideline recommendations, requiring concomitant behavioral modification and baseline BMI documentation where specified.

Definitions

BaselineRefers to baseline prior to the requested medication for weight loss

Baseline (orlistat specific)Refers to baseline prior to orlistat 120 mg (Xenical, authorized generic) unless otherwise specified

Revision History

08/01/2025policy_effective_dateLatest

Policy effective date set to 08/01/2025 and policy title updated to 'Appetite Suppressants and Orlistat' (from prior 'Weight Loss - Other Appetite Suppressants and Orlistat').

08/15/2024annual_revision

Annual revision: phentermine hydrochloride initial therapy updated to 3 months (from 4 months); continuing therapy weight-loss requirement increased from ≥4% to ≥5% of baseline body weight; Contrave continuing requirement updated to ≥5% weight loss; Qsymia initial adult therapy updated to 6 months (from 4 months), pediatric initial therapy updated to 6 months, and continuing weight-loss requirement changed to ≥5%; orlistat 120 mg adult initial therapy updated to 3 months (from 4 months).

Policy Summary

PayerCigna

PolicyAppetite Suppressants and Orlistat

Policy CodePolicy IP0420

Change TypeAnnual revision (criteria, durations, baseline clarifications, product list updates)

Effective DateAug 1, 2025

Next Review Date

Key ActionPrior authorization is required and providers must document baseline BMI and behavioral modification/diet trial and, for continuation, ≥5% weight loss or BMI reduction as specified.

SourceLink

On This Page

Prescriber documents why a preferred product is not appropriate (medical contraindication or prior intolerance).

Applies when a preferred product exists for the member's plan/employer (employer-specific brand/generic guidance applies).

Request is for a formulary/preferred product consistent with the member's benefit plan.

A) Initial Therapy (Contrave)

Covered when ALL of the following are met:

ALL of the following

Patient is an adult (≥ 18 years).
Patient has documentation of at least a 3-month trial of behavioral modification (diet and exercise) prior to initiation, unless prescriber documents why this is not appropriate or not feasible.
Baseline BMI/comorbidity
- BMI ≥ 30 kg/m2 (obese).
- BMI ≥ 27 kg/m2 with at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia, obstructive sleep apnea).
Prescriber documents concurrent continuation of behavioral modification while on therapy (dietary counseling, exercise plan, or structured behavioral program).
Contraindications to product are absent and prescriber attests to appropriate monitoring per product labeling (e.g., blood pressure, pulse, mental health status).

Adult Initial Therapy (Qsymia)

Covered when ALL of the following are met:

ALL of the following

Patient is an adult (≥ 18 years).
Patient has documentation of at least a 3-month trial of behavioral modification (diet and exercise) prior to initiation, unless prescriber documents why this is not appropriate or not feasible.
Baseline BMI/comorbidity
- BMI ≥ 30 kg/m2 (obese).
- BMI ≥ 27 kg/m2 with at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia, obstructive sleep apnea).
Prescriber documents concurrent continuation of behavioral modification while on therapy (dietary counseling, exercise plan, or structured behavioral program).

Adult Initial Therapy (Orlistat 120 mg)

Covered when ALL of the following are met:

ALL of the following

Patient is an adult (≥ 18 years).
Patient has documentation of at least a 3-month trial of behavioral modification (diet and exercise) prior to initiation, unless prescriber documents why this is not appropriate or not feasible.
Baseline BMI/comorbidity
- BMI ≥ 30 kg/m2 (obese).
- BMI ≥ 27 kg/m2 with at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia, obstructive sleep apnea).
Prescriber documents concurrent continuation of behavioral modification while on therapy (dietary counseling, exercise plan, or structured behavioral program).

Qsymia / Orlistat - Adult Initial Therapy (consolidated BMI/comorbidity and behavioral requirements)

Covered when ALL of the following are met:

ALL of the following

Patient meets the applicable age requirement (adult ≥ 18 years or pediatric as specified below).
Baseline BMI/comorbidity (Qsymia and Orlistat consolidated)
- BMI ≥ 30 kg/m2 (obese).
- BMI ≥ 27 kg/m2 with at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia, obstructive sleep apnea).
Prescriber documents at least a 3-month trial of behavioral modification (diet and exercise) prior to initiation for adult and pediatric patients where applicable, and continuation of behavioral modification concurrently with pharmacotherapy.
For pediatric Qsymia requests: patient is ≥ 12 years of age, prescriber documents prior intensive lifestyle program failure, and ongoing monitoring per pediatric guidance; obtain pediatric-specific dosing and evaluation plan consistent with labeling.
For pediatric Qsymia continuation therapy: documentation that treatment met response criteria at evaluation time points (e.g., ≥ 3% BMI reduction at 12 weeks on initial dose and ≥ 5% BMI reduction at subsequent evaluation as per product labeling) or other clinically appropriate response as documented by the prescriber.

Patient has lost ≥ 5% of baseline body weight≥ 5% of baseline body weight

Note: This refers to baseline prior to phentermine hydrochloride.

The medication will be used concomitantly with behavioral modification and a reduced-calorie diet

Contrave - Continuing Therapy

Approve when ONE of the following (Initial Therapy or Continuing Therapy) criteria are met:

B) Continuing Therapy (approve for 1 year)

Patient is ≥ 18 years of age
ANY of the following
- At baseline, patient had a BMI ≥ 30 kg/m2
- At baseline, patient had a BMI ≥ 27 kg/m2 AND at baseline had, or currently has, at least ONE weight-related comorbidity (hypertension; Type 2 diabetes; dyslipidemia; obstructive sleep apnea; cardiovascular disease; knee osteoarthritis; asthma; chronic obstructive pulmonary disease; metabolic-dysfunction associated steatotic liver disease/non-alcoholic fatty liver disease; polycystic ovarian syndrome; or coronary artery disease)
Patient has lost ≥ 5% of baseline body weight≥ 5% of baseline body weight
Note: This refers to baseline prior to Contrave.
The medication will be used concomitantly with behavioral modification and a reduced-calorie diet

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Qsymia - Adult Continuing Therapy

Approve when ONE of the following Adult or Pediatric criteria are met:

Adult Continuing Therapy (approve for 1 year)

Patient is ≥ 18 years of age
ANY of the following
- At baseline, patient had a BMI ≥ 30 kg/m2
- At baseline, patient had a BMI ≥ 27 kg/m2 AND at baseline had, or currently has, at least ONE weight-related comorbidity (hypertension; type 2 diabetes; dyslipidemia; obstructive sleep apnea; cardiovascular disease; knee osteoarthritis; asthma; COPD; metabolic-dysfunction associated steatotic liver disease/NAFLD; PCOS; or coronary artery disease)
Patient has lost ≥ 5% of baseline body weight≥ 5% of baseline body weight
Note: This refers to baseline prior to phentermine/topiramate extended-release (Qsymia, generic).
The medication will be used concomitantly with behavioral modification and a reduced-calorie diet

Top

Orlistat 120 mg - Adult Continuing Therapy

Approve when ONE of the following Adult or Pediatric criteria are met:

Adult Continuing Therapy (approve for 1 year)

Patient is ≥ 18 years of age
ANY of the following
- At baseline, patient had a BMI ≥ 30 kg/m2
- At baseline, patient had a BMI ≥ 27 kg/m2 AND at baseline had, or currently has, at least ONE weight-related comorbidity (hypertension; type 2 diabetes; dyslipidemia; obstructive sleep apnea; cardiovascular disease; knee osteoarthritis; asthma; COPD; metabolic-dysfunction associated steatotic liver disease/NAFLD; PCOS; or coronary artery disease)
Patient has lost ≥ 5% of baseline body weight≥ 5% of baseline body weight
Note: This refers to baseline prior to orlistat 120 mg (Xenical, authorized generic).
The medication will be used concomitantly with behavioral modification and a reduced-calorie diet

Top

Qsymia / Orlistat - Adult Continuing Therapy

Covered when ALL of the following are met:

Baseline BMI criteria for continuation

ANY of the following
- At baseline, the patient had a BMI ≥ 30 kg/m2
- Baseline BMI ≥ 27 kg/m2 with comorbidity: At baseline, the patient had a BMI ≥ 27 kg/m2 and at baseline had, or currently has, at least ONE weight-related comorbidity (hypertension; type 2 diabetes; dyslipidemia; obstructive sleep apnea; cardiovascular disease; knee osteoarthritis; asthma; chronic obstructive pulmonary disease; metabolic-dysfunction associated steatotic liver disease/non-alcoholic fatty liver disease; polycystic ovarian syndrome; or coronary artery disease)
Medication will be used concomitantly with behavioral modification and a reduced-calorie diet
Patient has lost ≥ 5% of baseline body weight≥ 5% of baseline body weight
Note: Clarifying baseline refers to baseline prior to orlistat 120 mg (Xenical, authorized generic).

Lifestyle Therapy Documentation

Document that the patient has participated in lifestyle therapy including behavioral modification and a reduced‑calorie diet, and that lifestyle interventions alone were inadequate. Include details of the behavioral program and dates of participation when available.

Documentation Required

Employer Plan Brand Exceptions

For employer plan members, if a brand product (for example, Adipex‑P or Lomaira) is requested when a generic equivalent is available, document the prescriber’s clinical rationale for the brand request (medical necessity or clinical justification).

Documentation Required

Document baseline BMI and comorbidities

Ensure the medical record documents baseline BMI and any weight‑related comorbidities (e.g., hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea) that support treatment in patients with BMI ≥27 kg/m2.

Billing Rule

Sample Product Not Acceptable for Criteria

Sample products are not acceptable documentation to meet prior authorization criteria; samples should not be billed as evidence of trial or therapy.

Billing Rule

Alli OTC

Over‑the‑counter orlistat (Alli) is not covered under the prescription criteria for orlistat 120 mg and does not meet prior authorization requirements for prescription coverage.

Denial Risk

Not Medically Necessary Uses

Use of these medications for indications not supported by FDA approval or this policy (for example, long‑term weight maintenance where the product is only indicated short‑term without documented justification, or for unapproved indications) will be considered not medically necessary.

Denial Risk

Avoid concomitant FDA‑approved weight‑loss medications

Avoid concomitant use of multiple FDA‑approved prescription weight‑loss medications unless clear clinical justification is documented; simultaneous use may result in denial as not medically necessary.

04/15/2025annual_revision

Revisions clarified 'baseline' language: BMI criteria changed to 'at baseline' for phentermine, Contrave, Qsymia, and orlistat; behavioral modification wording changed to state medication 'will be used concomitantly with behavioral modification and a reduced-calorie diet'; notes added clarifying baseline refers to baseline prior to the requested medication.

07/01/2025selected_revision

Selected revision: Lomaira (phentermine tablet) and phentermine/topiramate extended-release (generic to Qsymia) entries added to the policy and phentermine preferred product table updated to include Lomaira.

08/01/2025selected_revision

Selected revision clarified that 'Concomitant use with other medications FDA-approved for weight loss' is not recommended for approval and examples were updated to reflect current product availability.

conditions_removed

Conditions Not Covered list shortened: removed prior exclusions for treatment of hyperlipidemia in non-obese individuals, binge-eating disorder in non-obese individuals, and prevention of diabetes in individuals with BMI < 30 (or <27 with risk factors).

pediatric_criteria_change

Pediatric criteria: removed certain prior percentile requirements (85th-percentile rules) and clarified baseline references for pediatric Qsymia and orlistat; pediatric initial behavioral intervention duration retained (≥3 months) while failure clause was removed.

documentation_and_lifestyle

Documentation and provider action language standardized: require documentation of baseline BMI (prior to requested medication), trial of behavioral modification for at least 3 months before initial therapy, and that medication will be used concomitantly with behavioral modification and a reduced-calorie diet.