Appetite Suppressants and Orlistat Coverage Policy
Defines prior authorization requirements, medical necessity criteria, durations of approval, and limited employer-plan brand exceptions for phentermine hydrochloride, phentermine/topiramate (Qsymia/generic), Contrave, Lomaira, Adipex-P, and orlistat 120 mg (Xenical authorized generic). Applies to Cigna-administered health benefit plans subject to specific plan terms.
Policy Summary
PayerCigna
PolicyAppetite Suppressants and Orlistat Coverage Policy
Key ActionPrior Authorization is required for listed appetite suppressants and orlistat 120 mg; document baseline BMI and comorbidities and demonstrate ≥5% weight loss from baseline for continuing therapy.
Continuing therapy weight-loss requirement increased to ≥5% of baseline body weight (from ≥4%) for phentermine, Contrave, Qsymia, and orlistat.
Removed previous language requiring failure to achieve desired weight loss after behavioral modification; changed wording to 'has engaged in a trial' and 'medication will be used concomitantly with behavioral modification and a reduced-calorie diet.'
Lomaira and generic phentermine/topiramate were added to the policy; preferred product tables and employer plan exceptions added.
Removed coverage 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 kg/m2.
Concomitant use with other FDA-approved weight loss medications is not recommended for approval.
Clarified that baseline BMI and baseline weight refer to measurements prior to orlistat 120 mg (Xenical, authorized generic).
Lomaira (generic) added to the policy and criteria for Lomaira were added to the Phentermine Preferred Product Table.
Document notes removal then addition of Qsymia preferred product requirements across revisions.
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6Medications listed (examples)
≥5%Continuing therapy threshold (adults)
3–6 moInitial approval durations
≥30 / ≥27Adult BMI eligibility
≥95th pctPediatric BMI eligibility
Coverage Summary
This policy is covered with criteria for appetite suppressants (benzphetamine, diethylpropion, phendimetrazine, phentermine, phentermine/topiramate [Qsymia/generic], Lomaira, Contrave) and orlistat 120 mg (Xenical authorized generic). It summarizes FDA‑approved indications, required prior authorization, and the drug‑specific initial and continuing approval frameworks (durations and response assessment) for these products. The policy applies to health benefit plans administered by Cigna Companies and is interpreted per each plan's terms; benefit availability and determinations are subject to the applicable benefit plan document. The policy effective date is 03/01/2026.
Key thresholds and quick facts
Adult BMI eligibility (initial)At baseline: BMI ≥30 kg/m2 OR BMI ≥27 kg/m2 with ≥1 weight-related comorbidity (applies to adults for phentermine, Contrave, Qsymia, orlistat)
Pediatric BMI eligibility (initial)At baseline: BMI ≥95th percentile for age and sex for patients ≥12 and <18 years (Qsymia and orlistat pediatric criteria)
Continuing therapy response (adults)Patient must have lost ≥5% of baseline body weight to qualify for continuation (baseline refers to pre-medication measurement)
Continuing therapy response (pediatrics, Qsymia)Patient must have ≥5% reduction in BMI from baseline for pediatric continuing therapy with Qsymia
Prior authorization notePrior Authorization is required for listed agents (phentermine, phentermine/topiramate, Contrave, orlistat, etc.) and baseline measurements must be documented prior to the requested medication
Phentermine hydrochloride 2D Coverage Criteria
Phentermine hydrochloride — Coverage Criteria
Covered when ALL of the following apply. Note: “baseline” refers to measurements and comorbidity status documented before initiation of phentermine hydrochloride.
A) Initial Therapy
Patient is ≥ 16 years of age.
Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months.
iii. Baseline BMI/comorbidity
At baseline, patient had a body mass index (BMI) ≥ 30 kg/m2.
Baseline refers to status prior to starting phentermine hydrochloride.
Approve when ONE of the following (Initial Therapy or Continuing Therapy) is met:
A) Initial Therapy (approve 4 months)
Patient is ≥ 18 years of age
Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months
ANY of the following
At baseline, patient had a body mass index (BMI) ≥ 30 kg/m2
Note: This refers to baseline prior to Contrave.
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)
Orlistat 120 mg (Xenical authorized generic) - Weight Loss
Approve when ONE of the following (Adult or Pediatric Initial or Continuing Therapy) is met:
Adult Initial Therapy (approve 3 months)
Patient is ≥ 18 years of age
Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months
ANY of the following
At baseline, patient had a BMI ≥ 30 kg/m2
Note: This refers to baseline prior to orlistat 120 mg (Xenical, authorized generic).
Continuing Therapy — General Response Requirements
Denial Risk
Continuation Documentation and Denial Risk for Concomitant Use
For continuing therapy of any covered weight-loss medication, providers must document percent weight loss from baseline (≥5% for adults, or the applicable pediatric BMI reduction) and that the medication is being used concomitantly with behavioral modification and a reduced-calorie diet. Claims that indicate concomitant use of the requested agent with other FDA‑approved weight‑loss medications are not recommended for approval and may be denied.
Document percent weight loss from baseline (≥5% adults) and that therapy is used with behavioral modification and reduced-calorie diet.
Denial risk: concomitant use with other FDA‑approved weight‑loss medications is not recommended for approval and may be denied.
Conditions Not Recommended for Approval
Conditions Not Recommended for Approval
Covered when ALL of the following are met:
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For historical context, prior versions removed selected coverage exclusions (for example, treatment of hyperlipidemia in non‑obese individuals, binge‑eating disorder in non‑obese individuals, and prevention of diabetes in individuals with BMI < 30 kg/m2). These prior exclusions were removed during revisions and are presented here only for historical reference, not as active exclusions.
Applicable Drug / Product References
Drugs subject to prior authorization (listed examples)mixedCovered
Phentermine/topiramate extended-release (brand/generic references updated in revisions)
Lomaira
Generic Lomaira added to the policy
Phentermine
Preferred product table and phentermine products referenced
Provider Actions & Administrative Requirements
Prior Authorization
Prior Authorization Required — Listed Agents and Approval Durations
Prior Authorization is required for benzphetamine, diethylpropion, phendimetrazine, phentermine hydrochloride, phentermine/topiramate (Qsymia), Contrave, and orlistat 120 mg (Xenical authorized generic). Approvals are provided for the durations noted in the policy; where approvals are given in months, 1 month equals 30 days.
PA required for listed agents: benzphetamine, diethylpropion, phendimetrazine, phentermine HCl, Qsymia (phentermine/topiramate), Contrave, orlistat 120 mg.
Approval durations follow the policy; 1 month = 30 days.
Documentation Required
Required Baseline and Behavioral Modification Documentation
Documentation required for initial requests includes baseline BMI (measurements prior to the requested medication), specified weight-related comorbidities when applicable, and evidence the patient engaged in a trial of behavioral modification and dietary restriction for at least 3 months.
Clinical Evidence & Guidelines
3 moAssess response after 3 months on therapeutic dose (AACE 2025)
≥5%Continue therapy if weight loss 5% of baseline body weight
Evidence supporting the policy includes the AACE 2025 Update (AACE Consensus Statement) and drug-specific prescribing information (FDA labels, 2018–2025). Guideline recommendations (AACE 2025) inform the policy's ≥5% therapeutic response threshold and the timing for response assessment (assess after ~3 months on therapeutic dose). The policy also references individual product prescribing information that specifies evaluation timing and discontinuation criteria (drug labels 2018–2025).
Background & Definitions
This policy summarizes FDA‑approved indications and dosing/response evaluation recommendations for appetite suppressants and orlistat, and references AACE and AAP guidelines emphasizing that pharmacotherapy is an adjunct to lifestyle modification (behavioral modification and a reduced‑calorie diet).
Term
Definition
Baseline
Refers to measurements (BMI, weight) prior to initiation of the requested medication for weight loss.
Initial Therapy
Initial approval period specified per drug (3-6 months depending on agent).
Continuing Therapy
Subsequent approvals typically for 1 year contingent on documented weight-loss response.
Baseline (orlistat-specific)
Refers to baseline prior to orlistat 120 mg (Xenical, authorized generic) as clarified in the policy.
Revision History
03/01/2026policy_effectiveLatest
Policy effective date set to 03/01/2026; title 'Appetite Suppressants and Orlistat' and scope reaffirmed (prior authorization required for listed agents; Alli not recommended).
11/01/2025selected_revision
Preferred product requirements added for Qsymia; generic Qsymia was previously removed then handled in subsequent revisions; Lomaira (generic) added to policy and phentermine preferred-product table updated.
08/01/2025selected_revision
Policy Summary
PayerCigna
PolicyAppetite Suppressants and Orlistat Coverage Policy
Key ActionPrior Authorization is required for listed appetite suppressants and orlistat 120 mg; document baseline BMI and comorbidities and demonstrate ≥5% weight loss from baseline for continuing therapy.
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.
Baseline refers to status prior to starting phentermine hydrochloride.
Medication will be used concomitantly with behavioral modification and a reduced-calorie diet.
Concomitant use of multiple sympathomimetic appetite suppressants is prohibited; document current medications to confirm no contraindicated concomitant therapy.
Preferred product criteria is met for the product(s) as listed in the Preferred Product requirements and product-specific coverage.
B) Continuing Therapy
Patient is ≥ 16 years of age.
ii. Baseline BMI/comorbidity
At baseline, patient had a BMI ≥ 30 kg/m2.
Baseline refers to status prior to starting phentermine hydrochloride.
At baseline, patient had a BMI ≥ 27 kg/m2 AND at baseline patient 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.
Baseline refers to status prior to starting phentermine hydrochloride.
Continuing therapy approvals require documentation of clinical response: provider-documented weight loss or BMI reduction consistent with guideline-based expectations (e.g., ≥ 5% reduction in body weight after 3 months on therapeutic dose) or other plan-specified clinical improvement.
Preferred product criteria is met for the product(s) as listed in the Preferred Product requirements and product-specific coverage.
Prior Authorization
Provider Actions and Prior Authorization
Prior Authorization Required. Document baseline BMI (height/weight), baseline weight-related comorbidities, and baseline dates (measurements must be recorded prior to starting phentermine). Trials of lifestyle modification and dietary restriction must be documented. Preferred product rules apply; employer-plan brand exceptions require a trial of generic phentermine before Adipex-P or Lomaira brands are approved. Concomitant use of other sympathomimetic appetite suppressants with phentermine is prohibited and will be denied.
Prior authorization is required for all phentermine hydrochloride products (approvals issued for durations noted in policy).
Document baseline BMI, baseline weight (lbs or kg), baseline height, dates of measurements, and baseline comorbidities in the prior authorization submission.
Preferred product requirement: generic phentermine (or formulary preferred phentermine product) must be used prior to coverage of non-preferred brand formulations unless a documented medical reason or formulary exception is provided.
Employer-plan brand exception: where an employer-specific benefit requires brand trial exceptions, a trial of generic phentermine is required prior to coverage of Adipex-P or Lomaira brands.
Concomitant use prohibition: do not prescribe or approve phentermine concurrently with other sympathomimetic appetite suppressants; concurrent therapy is not covered.
Note: This refers to baseline prior to Contrave.
The medication will be used concomitantly with behavioral modification and a reduced-calorie diet
B) Continuing Therapy (approve 1 year)
Patient is ≥ 18 years of age
ANY of the following
At baseline, patient had a body mass index (BMI) ≥ 30 kg/m2
Note: This refers to baseline prior to Contrave.
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)
Note: This refers to baseline prior to Contrave.
Patient has lost ≥ 5% of baseline body weight≥ 5%
Note: This refers to baseline prior to Contrave.
The medication will be used concomitantly with behavioral modification and a reduced-calorie diet
Documentation Required
Contrave — Prior Authorization and Required Documentation
Prior Authorization is required for Contrave. Documentation for initial approval must include baseline BMI (at baseline prior to Contrave), relevant weight-related comorbidities when applicable, and evidence the patient engaged in a trial of behavioral modification and dietary restriction for at least 3 months. For continuation, document percent weight loss from baseline (≥5% of baseline body weight) and that the medication will be used concomitantly with behavioral modification and a reduced-calorie diet.
PA required for Contrave.
Document baseline BMI (prior to Contrave), comorbidities, and ≥3-month behavioral modification/diet trial for initial therapy.
For continuing therapy, document ≥5% weight loss from baseline and concomitant behavioral modification/reduced-calorie diet.
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)
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
Preferred product criteria is met for the product(s) as listed in the policy tables
Adult Continuing Therapy (approve 1 year)
Patient is ≥ 18 years of age
ANY of the following
At baseline, patient had a BMI ≥ 30 kg/m2
Note: This refers to baseline prior to phentermine/topiramate extended-release (Qsymia, generic).
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)
Note: This refers to baseline prior to phentermine/topiramate extended-release (Qsymia, generic).
Patient has lost ≥ 5% of baseline body weight≥ 5%
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
Pediatric Initial Therapy (approve 6 months)
Patient is ≥ 12 years of age and < 18 years of age
Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months
At baseline, patient had a body mass index (BMI) ≥ 95th percentile for age and sex
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
Preferred product criteria is met for the product(s) as listed in the policy tables
Pediatric Continuing Therapy (approve 1 year)
Patient is ≥ 12 years of age and < 18 years of age
At baseline, patient had a BMI ≥ 95th percentile for age and sex
Note: This refers to baseline prior to phentermine/topiramate extended-release (Qsymia, generic).
Patient has had a reduction in BMI of ≥ 5% from baseline≥ 5%
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
Prior Authorization
Qsymia / Phentermine-Topiramate — PA, Preferred Product Rules, and Documentation
Prior Authorization is required for phentermine/topiramate (Qsymia/generic) and other listed agents. Preferred-product requirements apply: Qsymia and phentermine products must meet preferred product criteria in the policy tables; employer-plan brand exceptions may require trial of the generic phentermine/topiramate before brand Qsymia. Documentation for initial and continuing therapy must include baseline BMI (prior to phentermine/topiramate), pediatric growth/BMI documentation for patients 12–17 (baseline BMI ≥95th percentile), and for continuation document percent weight loss from baseline (≥5% adults; ≥5% BMI reduction for pediatric continuing therapy) and concomitant behavioral modification/reduced-calorie diet.
PA required for Qsymia (phentermine/topiramate) and related products.
Preferred product criteria must be met for Qsymia and phentermine products per policy tables.
Employer-plan exception: trial of bioequivalent generic phentermine/topiramate required before brand Qsymia for some employer plans.
Continuation: adults must have ≥5% weight loss from baseline; pediatric continuing therapy requires ≥5% reduction in BMI from baseline; medication to be used with behavioral modification and reduced-calorie diet.
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)
Note: This refers to baseline prior to orlistat 120 mg (Xenical, authorized generic).
Patient is currently engaged in behavioral modification and on a reduced-calorie diet
Adult Continuing Therapy (approve 1 year)
Patient is ≥ 18 years of age
ANY of the following
At baseline, patient had a BMI ≥ 30 kg/m2
Note: This refers to baseline prior to orlistat 120 mg (Xenical, authorized generic).
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)
Note: This refers to baseline prior to orlistat 120 mg (Xenical, authorized generic).
Patient has lost ≥ 5% of baseline body weight≥ 5%
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
Pediatric Initial Therapy (approve 3 months)
Patient is ≥ 12 years of age and < 18 years of age
Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months
At baseline, patient had a body mass index (BMI) ≥ 95th percentile for age and sex
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
Pediatric Continuing Therapy (approve 1 year)
Patient is ≥ 12 years of age and < 18 years of age
At baseline, patient had a BMI ≥ 95th percentile for age and sex
Note: This refers to baseline prior to orlistat 120 mg (Xenical, authorized generic).
Patient has had a reduction in BMI percentile for age and weight (taking into account growth)
The medication will be used concomitantly with behavioral modification and a reduced-calorie diet
Billing Rule
Orlistat — Prior Authorization, Documentation, and Billing Rule
Prior Authorization is required for orlistat 120 mg (Xenical, authorized generic). Documentation must include baseline BMI/weight prior to orlistat 120 mg and for continuation show ≥5% loss of baseline body weight and that the medication will be used concomitantly with behavioral modification and a reduced-calorie diet. Alli (orlistat 60 mg) is not recommended for prior authorization or coverage.
PA required for orlistat 120 mg (Xenical, authorized generic).
Document baseline BMI/weight prior to orlistat 120 mg for initial and continuing therapy.
For continuation, document ≥5% loss of baseline body weight and concomitant behavioral modification/reduced-calorie diet.
Alli (orlistat 60 mg) is not recommended for PA/coverage.
Document baseline BMI prior to the requested medication.
Document relevant weight-related comorbidities when applicable.
Documentation for Continuing Therapy — Percent Weight Loss and Behavioral Modification
For continuation of therapy, document percent weight loss from baseline (adults: ≥5% of baseline body weight). For pediatric phentermine/topiramate (Qsymia), document a reduction in BMI ≥5% from baseline. In all cases continuing therapy must be used concomitantly with behavioral modification and a reduced‑calorie diet.
Adults: document ≥5% loss of baseline body weight for continuation.
Pediatrics (Qsymia): document ≥5% reduction in BMI from baseline for continuation.
Document concomitant behavioral modification and reduced‑calorie diet.
Denial Risk
Denial Risk — Concomitant Use with Other FDA‑Approved Weight‑Loss Medications
Claims that indicate concomitant use with other FDA‑approved weight‑loss medications are not recommended for approval and may be denied.
Concomitant use with other FDA‑approved weight‑loss medications is a condition not recommended for approval.
Billing Rule
Billing, Employer-Plan Exceptions, and Preferred-Product Rules
Coverage and billing specifics: Alli (orlistat 60 mg) is not recommended for prior authorization or coverage. Employer-plan brand exceptions exist that may require a trial of generic phentermine (or generic phentermine/topiramate for Qsymia) with documented intolerance to inactive ingredients before brand approval. Preferred-product requirements apply for Qsymia and phentermine products and must be met per the policy tables.
Alli (orlistat 60 mg) is not recommended for PA/coverage.
Employer-plan brand exceptions: trial of generic phentermine (or generic phentermine/topiramate for Qsymia) required with documented intolerance to inactive ingredients for brand approval.
Preferred product requirements for Qsymia and phentermine products must be met per policy tables.
Clarified 'Conditions Not Recommended for Approval' to specify concomitant use with other medications FDA‑approved for weight loss is not recommended; examples updated to reflect product availability.
07/01/2025selected_revision
Lomaira added to policy; phentermine preferred-product table criteria updated to include Lomaira; generic phentermine/topiramate entries added.
04/15/2025annual_revision
Multiple clarifications and material changes: baseline defined as prior to the requested medication; initial approval durations reduced for several agents (phentermine and orlistat initial therapy to 3 months, Qsymia initial therapy to 6 months); continuing therapy weight‑loss requirement increased from ≥4% to ≥5% of baseline for phentermine, Contrave, Qsymia, and orlistat; language changed to require that medication 'will be used concomitantly with behavioral modification and a reduced‑calorie diet' and removed prior 'failure' wording after behavioral intervention.
08/15/2024annual_revision
Policy name changed (previous title: 'Weight Loss Medications' to 'Weight Loss - Other Appetite Suppressants and Orlistat'); phentermine initial therapy updated to 3 months (from 4); weight‑loss response threshold changed to ≥5% of baseline.
various (documented across revisions)criteria_clarification
Eligibility BMI language standardized to reference 'at baseline' (measurements prior to initiation of the requested medication) and comorbidity list expanded/standardized across agents (same enumerated comorbidities added as baseline notes).
various (documented across revisions)removal
Removed prior coverage exclusions: treatment of hyperlipidemia in non‑obese individuals, binge‑eating disorder in non‑obese individuals, and prevention of diabetes in individuals with BMI <30 kg/m2 (Conditions Not Covered updated).