CurrentColorado Rocky Mountain Health PlansPolicy N/A

Obesity Treatment Agents prior authorization criteria (DHS Pharmacy Services)

A prior authorization form and clinical criteria for initial and renewal coverage of obesity treatment agents (including special handling for amphetamine-containing agents and non-preferred agents) for Colorado Rocky Mountain Health Plans / DHS Pharmacy Services. It specifies patient eligibility (age, BMI, comorbidities), documentation requirements, drug-class exceptions, urine drug screening for stimulants, and renewal response thresholds.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyObesity Treatment Agents prior authorization criteria (DHS Pharmacy Services)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionProviders must complete the Obesity Treatment Agents prior authorization form and fax it with required clinical documentation to DHS - Pharmacy Division; DX code is required on the form.

SourceLink

POLICY UPDATE CHANGES

No material changes to clinical coverage or criteria

3Primary criteria sections (Initial adult, Initial pediatric, Renewal)

2Special-agent pathways (amphetamine-containing; non-preferred)

1Required UDS for controlled-substance agents

Coverage Summary

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This is a prior authorization (PA) form and associated clinical criteria for coverage of obesity treatment agents administered via the DHS Pharmacy Services program. Coverage is covered with criteria and applies to initial and renewal requests for adults and pediatrics per the form. GLP-1 receptor agonists are not covered for treatment of overweight or obesity and must use a separate GLP-1 Receptor Agonists form. The criteria include specific pathways for amphetamine-containing agents (e.g., Evekeo) with enhanced documentation and urine drug screening requirements, and for non-preferred agents that require trial/failure or contraindication to preferred agents. Effective date: 2026-01-01. Status: CURRENT.

Surface thresholds

Adult BMI (primary)>= 30 kg/m2

Adult BMI (alternative)>= 27 and < 30 kg/m2 with at least one weight-related comorbidity

Pediatric BMI>= 95th percentile for age and sex (CDC charts)

Renewal response timeframe>= recommended cutoff in FDA-approved labeling, peer-reviewed literature, or consensus guidelines after 3 months at maximum recommended/tolerated dose

Medical Necessity Criteria

Initial requests (adults and pediatrics) and special-agent requirements

Covered when ALL of the following are met:

Beneficiary is 18 years of age or older

Adult BMI criteria (ANY of the following)
- Has a BMI greater than or equal to 30 kg/m2
- BMI 27–<30 plus comorbidity
  - Has a BMI greater than or equal 27 kg/m2 and less than 30 kg/m2
  - AND at least one weight-related comorbidity (cardiovascular disease, dyslipidemia, hypertension, metabolic syndrome, obstructive sleep apnea, prediabetes, type 2 diabetes, other)
- Candidate based on adiposity/waist circumference/BMI exceptions
  - Is a candidate for treatment based on degree of adiposity, waist circumference, history of bariatric surgery, BMI exceptions for beneficiary's ethnicity, etc.
  - AND has at least one weight-related comorbidity (cardiovascular disease, dyslipidemia, hypertension, metabolic syndrome, obstructive sleep apnea, prediabetes, type 2 diabetes, other)

Beneficiary is less than 18 years of age

Beneficiary is less than 18 years of age
Has a BMI in the 95th percentile or greater standardized for age and sex based on current CDC charts

General documentation and attestation

Submit diagnosis and documentation (DX code required)
Prescriber attestation that beneficiary was recently counseled about lifestyle changes and behavior modifications (healthy diet and increased physical activity)
Submit documentation for contraindications to requested drug if present

Requests for Evekeo (amphetamine) or any amphetamine-containing obesity treatment agent

Assessed for potential risk of misuse, abuse, and/or addiction based on family and social history
Was educated regarding potential adverse effects of stimulants, including risk of misuse, abuse, and addiction
Has a history of trial and failure of or a contraindication or an intolerance to all other Obesity Treatment Agents (preferred and non-preferred)
Has prescriber documentation explaining why the requested drug is needed and a plan for tapering
If history of substance dependency/abuse/diversion
- Has results of a recent UDS for licit and illicit drugs with the potential for abuse (including specific testing for oxycodone, fentanyl, and tramadol) that is consistent with prescribed controlled substances

Requests for any other non-preferred obesity treatment agent

Has a history of trial and failure of or a contraindication or an intolerance to the preferred Obesity Treatment Agents approved or medically accepted for the beneficiary's diagnosis or indication
Refer to papdl.com/preferred-drug-list for list of preferred and non-preferred drugs

Renewal requests

Covered continuations when ALL of the following are met:

Age-specific measurement documentation

For beneficiaries 18 years or older
- Provide pre-treatment weight and current weight
For beneficiaries less than 18 years of age
- Provide pre-treatment BMI and current BMI
- Provide pre-treatment BMI z-score and current BMI z-score

Clinical benefit and response criteria (ALL)

Provider Actions & Documentation Requirements

Prior Authorization

Complete and fax PA form with documentation

Providers must complete the Obesity Treatment Agents prior authorization form and fax it with required clinical documentation to DHS - Pharmacy Division. The form requires a diagnosis code (DX code) to be entered.

Documentation Required

Counseling attestation

Prescriber must attest that the beneficiary was recently counseled about lifestyle changes and behavior modifications such as a healthy diet and increased physical activity.

Documentation Required

BMI/weight documentation

Provide pre-treatment and current weight and BMI on initial and renewal requests as specified. For beneficiaries under 18 years, include pre-treatment and current BMI z-score.

Documentation Required

UDS for stimulant agents

For initial and renewal requests for Evekeo or other amphetamine-containing agents, submit recent urine drug screen (UDS) results for licit and illicit drugs with potential for abuse, including specific testing for oxycodone, fentanyl, and tramadol, especially when there is a history of substance misuse/dependency/diversion.

Documentation Required

Failure of preferred agents for non-preferred requests

For requests (initial or renewal) of non-preferred obesity treatment agents, submit documentation of trial and failure of, or a contraindication or intolerance to, preferred Obesity Treatment Agents. Refer to papdl.com/preferred-drug-list for the list of preferred and non-preferred drugs.

Documentation Required

Prescriber explanation and taper plan for stimulants

For initial and renewal requests for amphetamine-containing agents, prescriber must provide documentation explaining why the requested drug is needed and include a plan for tapering.

Background & Definitions

This PA form collects prescriber and office contact information, beneficiary identifiers (name, DOB, ID), and the requested drug details (drug name, strength, dosage form, directions, quantity, refills) and requires a diagnosis with DX code. The form provides PA guidance and links to DHS Pharmacy Services resources and quantity/dose limits. It explicitly states that requests for drugs containing a GLP-1 receptor agonist should use the GLP-1 Receptor Agonists fax form and that GLP-1 receptor agonists are not covered for overweight or obesity. The form documents clinical information to support PA decisions including pre-treatment and current weight/BMI (and BMI z-score for children), prescriber attestation of counseling about lifestyle changes, documentation of contraindications, and specific items for special-agent requests (e.g., assessment of misuse risk, education on stimulant adverse effects, prescriber taper plan, and submission of recent urine drug screen results when indicated). Completed forms and required clinical documentation must be faxed to DHS - Pharmacy Division.

Definitions: Non-preferred agent — An obesity treatment agent not listed as preferred on the plan's preferred drug list (refer to papdl.com for the preferred drug list).

OpenPayer

Obesity Treatment Agents prior authorization criteria (DHS Pharmacy Services)

Coverage Summary

Medical Necessity Criteria

Provider Actions & Documentation Requirements

Coding

Background & Definitions

Revision History