CurrentGeorgia Department of Community HealthPolicy N/A

Georgia Medicaid FFS — Antihyperlipidemics (Xenical, Saxenda) prior authorization

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This policy governs prior authorization requirements and coverage criteria for Xenical (orlistat) and Saxenda (liraglutide) for Georgia Medicaid fee-for-service members, primarily addressing use in adolescents aged 12–17 years.

Policy Summary

PayerGeorgia Department of Community Health

PolicyAntihyperlipidemics (Xenical, Saxenda) prior authorization — Georgia Medicaid FFS

Policy CodePolicy N/A

Change TypeNo material change noted

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization via OptumRx for members aged 12–17; PA is valid for 1 year.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 yearLength of authorization

12-17Age range

>=27Min BMI Xenical

>=30Min BMI Saxenda

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CurrentGeorgia Department of Community HealthPolicy N/A

Georgia Medicaid FFS — Antihyperlipidemics (Xenical, Saxenda) prior authorization

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Policy Summary

PayerGeorgia Department of Community Health

PolicyAntihyperlipidemics (Xenical, Saxenda) prior authorization — Georgia Medicaid FFS

Policy CodePolicy N/A

Change TypeNo material change noted

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization via OptumRx for members aged 12–17; PA is valid for 1 year.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 yearLength of authorization

12-17Age range

>=27Min BMI Xenical

>=30Min BMI Saxenda

Coverage Criteria

Xenical (orlistat) — Initial approval

Covered when ALL of the following are met

Xenical criteria: Member is 12 to 17 years of age

Xenical criteria: Diagnosis of hypercholesterolemia or hyperlipidemia

Xenical criteria: Currently taking lipid-lowering medications

Xenical criteria: Initial body mass index (BMI) >= 27 kg/m2>= 27 kg/m2

Xenical criteria: Medication will be used as an adjunct to a reduced-calorie diet and increased physical activity

Saxenda (liraglutide) — Initial approval

Covered when ALL of the following are met

Saxenda criteria: Member is 12 to 17 years of age

Saxenda criteria: Diagnosis of hypercholesterolemia or hyperlipidemia

Saxenda criteria: Currently taking lipid-lowering medications

Saxenda criteria: Member weighs > 60 kg> 60 kg

Saxenda criteria: Initial body mass index (BMI) >= 30 kg/m2

This policy excludes coverage of Xenical (orlistat) and Saxenda (liraglutide) for members who are younger than 12 years of age or who are 18 years of age and older. Only members aged 12 through 17 years may be considered for authorization under the criteria in this policy.

Initial Therapy Criteria

Initial therapy criteria

Initial approval rules by drug

Xenical initial: See Xenical criteria: age 12-17, diagnosis of hypercholesterolemia or hyperlipidemia, current use of lipid-lowering medications, BMI >=27 kg/m2, adjunct to diet and exercise

Saxenda initial: See Saxenda criteria: age 12-17, diagnosis of hypercholesterolemia or hyperlipidemia, current use of lipid-lowering medications, weight >60 kg, BMI >=30 kg/m2, adjunct to diet and exercise, and prior inadequate response/allergy/contraindication/drug interaction/intolerance to Xenical

Saxenda requires trial/failure/intolerance to Xenical

Continuation / Renewal

Continuation/renewal

Duration of authorization

Authorization duration: Approved prior authorizations are valid for 1 year

Renewal through PA process required for continued coverage

Provider Actions & Requirements

Prior Authorization

Prior authorization required (OptumRx; 1 year)

Prior authorization is required for Xenical (orlistat) and Saxenda (liraglutide) for members aged 12–17. Providers must obtain PA through OptumRx; approved authorizations are valid for 1 year.

Step Therapy

Step requirement: trial or intolerance to Xenical

Before Saxenda will be approved, the request must document that the member experienced an inadequate response, allergy, contraindication, drug–drug interaction, or intolerable side effect with Xenical (orlistat).

Documentation Required

Required documentation and PA submission

Coding & Clinical Thresholds

inv-04: BMI for Xenical — >= 27 kg/m2

Minimum BMI>= 27 kg/m2

Age range12 to 17 years

Required diagnosisHypercholesterolemia or hyperlipidemia

Concomitant therapyCurrently taking lipid-lowering medications

Use contextMedication must be used as an adjunct to a reduced-calorie diet and increased physical activity

inv-05: BMI for Saxenda — >= 30 kg/m2

Minimum BMI>= 30 kg/m2

Step Therapy Requirements

Step	Required prior agent	Requirement detail
1	Xenical (orlistat)	Documentation of inadequate response, allergy, contraindication, drug–drug interaction, or intolerable side effect with Xenical is required prior to approval of Saxenda (liraglutide).

Quantity Limits

inv-15: See QLL resource — per Preferred Drug List / Quantity Level Limits

Quantity limits referencePer Preferred Drug List / Quantity Level Limits (QLL) available at www.mmis.georgia.gov/portal under Provider Manuals -> Pharmacy Services

Access methodOnline via MMIS Georgia provider portal, Provider Manuals, Pharmacy Services section

ScopeApplies to quantity level limitations for listed medications

Definitions

inv-11: Adjunct therapy — medication use in addition to reduced-calorie diet and increased physical activity

DefinitionMedication use in addition to a reduced-calorie diet and increased physical activity as part of weight and lipid management.

Clinical roleRequired context for approval of Xenical and Saxenda (both policies state use as adjunct to diet and increased physical activity)

ApplicabilityApplies to members aged 12 to 17 with hypercholesterolemia or hyperlipidemia when meeting other drug-specific criteria

Background

This policy addresses the use of two anti-hyperlipidemic/weight-management agents, Xenical (orlistat) and Saxenda (liraglutide), in Georgia Medicaid fee-for-service adolescent members diagnosed with hypercholesterolemia or hyperlipidemia. Coverage is limited to use as an adjunct to a reduced-calorie diet and increased physical activity and requires prior authorization for members aged 12–17 years per the program’s PA process.