CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior Authorization/Notification - Weight Loss/Appetite Suppression Medication Coverage

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This optional clinical pharmacy program governs prior authorization and notification for weight loss and appetite-suppression medications when a client or business has elected to cover these products. It applies to providers requesting coverage for eligible patients, including certain cardiovascular, MASH, and obstructive sleep apnea indications.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization/Notification - Weight Loss/Appetite Suppression Medication Coverage

Policy CodePolicy N/A

Change TypeMaterial update

Effective DateOct 1, 2026

Last ReviewSep 1, 2020

Next Review DateN/A

Key ActionDocument the requested medication and indication, patient age, BMI or pediatric BMI percentile, qualifying weight-related comorbidity, and use with lifestyle modification.

SourceLink

POLICY UPDATE CHANGES

Coverage was added for Wegovy injection for metabolic dysfunction-associated steatohepatitis (MASH) with moderate to advanced liver fibrosis.

Coverage was added for Zepbound for moderate to severe obstructive sleep apnea.

Wegovy tablet and Wegovy HD were added to the program criteria, with Wegovy criteria differentiated by indication.

The policy clarified that no BMI requirement applies when Wegovy injection is requested for the MASH indication.

Foundayo and Wegovy HD were added to the covered medication criteria.

The program removed references to regulatory requirements and changed the exclusion language for Foundayo and Wegovy tablets.

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CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior Authorization/Notification - Weight Loss/Appetite Suppression Medication Coverage

Customize your policy alerts

Sign up for all Colorado Rocky Mountain Health Plans policy alerts

Know when Colorado Rocky Mountain Health Plans releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization/Notification - Weight Loss/Appetite Suppression Medication Coverage

Policy CodePolicy N/A

Change TypeMaterial update

Effective DateOct 1, 2026

Last ReviewSep 1, 2020

Next Review DateN/A

Key ActionDocument the requested medication and indication, patient age, BMI or pediatric BMI percentile, qualifying weight-related comorbidity, and use with lifestyle modification.

SourceLink

POLICY UPDATE CHANGES

Coverage was added for Wegovy injection for metabolic dysfunction-associated steatohepatitis (MASH) with moderate to advanced liver fibrosis.

Coverage was added for Zepbound for moderate to severe obstructive sleep apnea.

Wegovy tablet and Wegovy HD were added to the program criteria, with Wegovy criteria differentiated by indication.

The policy clarified that no BMI requirement applies when Wegovy injection is requested for the MASH indication.

Foundayo and Wegovy HD were added to the covered medication criteria.

The program removed references to regulatory requirements and changed the exclusion language for Foundayo and Wegovy tablets.

13Listed weight loss or appetite-suppression medications/products

12 monthsMaximum listed reauthorization period

3–6 monthsInitial authorization periods

≥5%Typical reauthorization weight-loss threshold

F2–F3Required fibrosis stage for Wegovy MASH

OptionalProgram availability

Coverage Criteria

Initial Therapy

Initial authorization is covered when ALL of the following are met.

Initial authorization requirements

Qualifying indication
- Treatment is requested for appetite suppression or weight loss.
- Wegovy injection or tablet is requested for risk reduction of major adverse cardiovascular events in a patient with established cardiovascular disease, including prior myocardial infarction, ischemic or hemorrhagic stroke, or peripheral arterial disease.
- Wegovy injection is requested for treatment of metabolic dysfunction-associated steatohepatitis (MASH) with moderate to advanced liver fibrosis.Fibrosis stage F2 or F3
- Zepbound is requested for moderate to severe obstructive sleep apnea.
Age requirement
- The patient is at least 12 years of age for Qsymia, Saxenda, Wegovy injection, or Xenical.≥ 12 years
- The patient is older than 16 years of age for all other listed medications.> 16 years
Lifestyle and eligibility requirements
- The medication is used as an adjunct to lifestyle modification, such as dietary or caloric restriction, exercise, behavioral support, or a community-based program.
- Weight or BMI qualification
  - The patient has a BMI of at least 30 kg/m²; pediatric patients have a BMI above the 95th percentile.BMI ≥ 30 kg/m², or pediatric BMI > 95th percentile
  - The patient has a BMI of at least 27 kg/m² and a weight-related comorbidity, such as dyslipidemia, hypertension, type 2 diabetes, or sleep apnea.BMI ≥ 27 kg/m² with a weight-related comorbidity
  - Wegovy injection is requested for treatment of MASH.
    No BMI requirement applies to the Wegovy injection MASH indication.

Continuation Therapy

Reauthorization is covered when BOTH of the following requirements are met.

Reauthorization requirements

Medication-specific response or titration criterion
- The patient has achieved weight loss of at least 3% of baseline body weight while receiving Qsymia.≥ 3% of baseline body weight
- The patient has achieved weight loss of at least 4% of baseline body weight while receiving Saxenda.≥ 4% of baseline body weight
- Wegovy injection for MASH
  - Wegovy injection is requested for treatment of MASH.

Wegovy tablets are typically excluded from coverage. Coverage may also be subject to applicable benefit, formulary, and supply limitations.

Eligibility Thresholds and Clinical Parameters

Adult obesity BMI

Eligibility groupAdult obesity

BMI threshold≥ 30 kg/m2

Clinical useQualifies under the obesity BMI criterion when used as an adjunct to lifestyle modification

Overweight BMI with comorbidity

BMI threshold≥ 27 kg/m2

Additional requirementA qualifying weight-related comorbidity is required

Examples of comorbidityDyslipidemia, hypertension, type 2 diabetes, or sleep apnea

Authorization, Documentation, and Coverage Administration

Prior Authorization

Confirm the optional coverage election

Prior authorization or notification applies to the listed weight loss and appetite-suppression medications only when the client or business has elected to cover weight loss products under this optional program.

Prior Authorization

Initial authorization periods vary by medication

Initial authorization is issued for a medication-specific period. Submit requests with the applicable duration in mind.

3 months: benzphetamine, diethylpropion, phendimetrazine, and phentermine
4 months: Contrave, Qsymia, and Saxenda
5 months: Wegovy injection or tablet and Wegovy HD
6 months: Foundayo, Xenical, and Zepbound

Program Background

This optional program governs prior authorization and notification for selected weight loss and appetite-suppression medications when the client or business has elected to cover these products. It addresses pharmacologic treatment for obesity and overweight with a weight-related comorbidity, used as an adjunct to lifestyle modification such as dietary or caloric restriction, exercise, behavioral support, or a community-based program.

Coverage also includes selected product-specific indications: cardiovascular risk reduction with established cardiovascular disease, metabolic dysfunction-associated steatohepatitis (MASH) with moderate to advanced fibrosis, and moderate to severe obstructive sleep apnea.

Key Definitions

MASH

TermMetabolic dysfunction-associated steatohepatitis

Former nameNonalcoholic steatohepatitis (NASH)

Fibrosis contextModerate to advanced liver fibrosis, specifically stage F2 or F3

BMI eligibility

Adult obesityBMI ≥ 30 kg/m2

Overweight with comorbidityBMI ≥ 27 kg/m2 with a weight-related comorbidity

Pediatric obesityBMI > 95th percentile

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization/Notification - Weight Loss/Appetite Suppression Medication Coverage

Policy CodePolicy N/A

Change TypeMaterial update

Effective DateOct 1, 2026

Last ReviewSep 1, 2020

Next Review DateN/A

Key ActionDocument the requested medication and indication, patient age, BMI or pediatric BMI percentile, qualifying weight-related comorbidity, and use with lifestyle modification.

SourceLink

On This Page

Positive clinical response to Wegovy injection is documented, such as improvement in or stabilization of fibrosis.

The patient has not progressed to cirrhosis.

The patient receiving Wegovy injection or tablet, or Wegovy HD for weight loss, has achieved weight loss of at least 5% of baseline body weight.≥ 5% of baseline body weight

The patient receiving another appetite suppressant has achieved weight loss of at least 5% of baseline body weight.≥ 5% of baseline body weight

For Foundayo, Saxenda, Wegovy injection or tablet, or Zepbound, the patient has been on therapy for six months or less and has not yet titrated to a maintenance dose.On therapy ≤ 6 months

Continuation of lifestyle modification is documented.

Pediatric obesity

Eligibility groupPediatric patients

BMI threshold> 95th percentile

Clinical useQualifies under the pediatric obesity criterion when used as an adjunct to lifestyle modification

Pediatric age threshold for selected medications

Minimum age≥ 12 years

MedicationsQsymia, Saxenda, Wegovy injection, and Xenical

ApplicationThis age threshold applies to the listed medications

Age threshold for other listed medications

Minimum age> 16 years

ScopeAll other listed medications

Age ruleThe patient must be older than 16 years for these medications

Qsymia reauthorization weight loss

MedicationQsymia

Required weight loss≥ 3% of baseline body weight

TimingRequired for reauthorization

Saxenda reauthorization weight loss

MedicationSaxenda

Required weight loss≥ 4% of baseline body weight

TimingRequired for reauthorization

Wegovy and Wegovy HD weight-loss reauthorization

MedicationsWegovy injection or tablet and Wegovy HD for weight loss

Required weight loss≥ 5% of baseline body weight

TimingRequired for reauthorization

Other appetite suppressant reauthorization weight loss

Medication groupAll other appetite suppressants

Required weight loss≥ 5% of baseline body weight

TimingRequired for reauthorization

MASH fibrosis

IndicationWegovy injection for metabolic dysfunction-associated steatohepatitis (MASH)

Qualifying fibrosisModerate to advanced liver fibrosis

Required stageF2 or F3

Prior Authorization

Use the correct reauthorization duration

Reauthorization is issued for 12 months for most listed products and 6 months for the specified appetite suppressants. Ensure continuation criteria are documented before requesting renewal.

12 months: Contrave, Foundayo, Qsymia, Saxenda, Wegovy injection or tablet, Wegovy HD, Xenical, and Zepbound
6 months: benzphetamine, diethylpropion, phentermine, and phendimetrazine

Prior Authorization

Request the titration extension when applicable

A one-time 6-month authorization may be issued to allow Foundayo, Saxenda, Wegovy injection or tablet, or Zepbound to be titrated to a maintenance dose when the patient has been on therapy for six months or less.

Documentation Required

Submit complete initial clinical documentation

Document the requested medication and indication, patient age, BMI or pediatric BMI percentile, any qualifying weight-related comorbidity, and use as an adjunct to lifestyle modification.

Include the applicable indication, such as appetite suppression or weight loss, cardiovascular risk reduction, MASH, or moderate to severe obstructive sleep apnea.
Document lifestyle modification, such as dietary or caloric restriction, exercise, behavioral support, or a community-based program.
For MASH, document moderate to advanced liver fibrosis, specifically fibrosis stage F2 or F3.

Documentation Required

Document response before reauthorization

For reauthorization, document baseline body weight and the medication-specific percentage of weight loss. For Wegovy MASH therapy, document the indication, positive clinical response such as improvement or stabilization of fibrosis, and that the patient has not progressed to cirrhosis.

Qsymia: weight loss of at least 3% of baseline body weight
Saxenda: weight loss of at least 4% of baseline body weight
Wegovy injection or tablet and Wegovy HD for weight loss, and all other appetite suppressants: weight loss of at least 5% of baseline body weight

Documentation Required

Maintain lifestyle and titration documentation

Document continuation of lifestyle modification. For Foundayo, Saxenda, Wegovy, and Zepbound when applicable, also document that the patient has been on therapy for six months or less and has not yet titrated to a maintenance dose.

Denial Risk

Missing initial criteria can result in denial

Initial authorization may be denied when the requested indication, patient age, lifestyle-modification requirement, BMI or pediatric percentile requirement, or qualifying weight-related comorbidity criteria are not met.

Confirm the medication and indication are included in the criteria.
Verify the applicable age threshold.
Document use as an adjunct to lifestyle modification.
Verify BMI of at least 30 kg/m2, BMI of at least 27 kg/m2 with a weight-related comorbidity, pediatric BMI above the 95th percentile, or the applicable Wegovy MASH pathway.

Denial Risk

Document every continuation requirement

Reauthorization may be denied when the required weight loss or positive clinical response is not documented, lifestyle modification has not continued, the patient has progressed to cirrhosis for the MASH indication, or other medication-specific continuation criteria are not met.

Billing Rule

Check benefit and supply limitations

Coverage may be limited by the member-specific benefit plan, applicable federal requirements, supply limits, and medication-specific formulary rules. Wegovy tablets are typically excluded from coverage.

State mandates may apply.
Any federal regulatory requirements and the member-specific benefit plan may impact coverage criteria.
Supply limits may be in place.
Refer to nonformulary Wegovy or Zepbound criteria for plans that do not cover weight loss medications.

Established cardiovascular disease

Prior myocardial infarctionIncluded as established cardiovascular disease

StrokeIschemic or hemorrhagic stroke is included

Peripheral arterial diseaseIncluded as established cardiovascular disease