CurrentHealth NetPolicy CA.CP.PMN.02

Weight Loss Agents

Defines medical necessity criteria and authorization rules for pharmacologic weight loss agents for Health Net / California Health and Wellness Medicaid members in California.

Policy Summary

PayerHealth Net

PolicyWeight Loss Agents

Policy CodePolicy CA.CP.PMN.02

Change TypeNo material changes

Effective DateJan 15, 2021

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of current BMI, program enrollment in a reduced-calorie diet and increased physical activity, age per FDA labeling, and medication-specific contraindication screening.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

BMI ≥30 or BMI ≥27+comorbidityEligibility BMI threshold

12 weeksInitial authorization

6 monthsContinuation interval

Sympathomimetics 12 wksShort-term agents

Age 12–18 >60 kgPediatric Saxenda

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Initial Approval Criteria (applies to all weight loss agents)

Weight loss agents are medically necessary when ALL of the following are met:

Initial approval prerequisites: A. Documented current BMI ≥ 30 OR BMI ≥ 27 with at least one qualifying comorbidity (cardiovascular disease, hypertension, dyslipidemia, diabetes, elevated waist circumference or other obesity-related medical condition); B. Documentation that member is actively enrolled in a reduced-calorie diet and increased physical activity weight loss program adjunct to therapy; C. Age appropriate per FDA labeling for the requested medication; D. Member is NOT receiving two medications for weight loss at the same time.

Orlistat (Xenical) specific criteria

In addition to Initial Approval Criteria, ALL of the following must be met:

Orlistat prerequisites: A. Criteria A-D in Initial Approval Criteria are met; B. Negative history of cholestasis or chronic intestinal malabsorption in the past 12 months; C. Treatment protocol: initial approval 12 weeks up to 360 mg/day; continued approval 6 months if member has lost at least 5% of initial body weight during the first 12 weeks of therapy, has a BMI ≥ 25, maintains initial weight loss, dose does not exceed 360 mg/day, and continues to meet all above criteria.

Phentermine/Topiramate (Qsymia) specific criteria

In addition to Initial Approval Criteria, ALL of the following must be met:

Qsymia prerequisites: A. Criteria A-D in Initial Approval Criteria are met; B. Negative history of MAOI therapy in the last 14 days, glaucoma, or hyperthyroidism; C. Treatment protocol: initial approval 12 weeks up to 7.5 mg/46 mg per day; continued approval 6 months up to 15 mg/92 mg per day if member has lost at least 5% of initial weight during the first 12 weeks, has a BMI ≥ 25, maintains initial weight loss, dose does not exceed 15 mg/92 mg per day, and continues to meet all above criteria.

Liraglutide (Saxenda) specific criteria

Must meet ALL of the following (adult OR pediatric pathways):

Age pathway: Either: 1) Adults: meet Initial Approval Criteria A-D; OR 2) Pediatrics: meet Criteria B-D, age 12–18 years, body weight > 60 kg, and an initial BMI corresponding to adult BMI 30 kg/m2 by international cut-offs.

Additional Saxenda prerequisites: B. Not being used to treat diabetes; C. Member is not on insulin or another GLP-1 receptor agonist; D. Negative personal or family history of medullary thyroid carcinoma (MTC) or MEN2; E. Treatment protocol: initial approval 12 weeks up to 3 mg/day; continued approval 6 months if adults have lost at least 4% of baseline body weight (or pediatrics have had at least 1% reduction in baseline BMI after maintenance dose), have a BMI ≥ 25, maintain initial weight loss, dose does not exceed 3 mg/day, and continue to meet all above criteria. Note: Saxenda prescribing information recommends evaluating weight change at 16 weeks for adults and discontinuing if <4% weight loss; pediatrics evaluated after 12 weeks on maintenance dose per Appendix.

Naltrexone/Bupropion (Contrave) specific criteria

In addition to Initial Approval Criteria, ALL of the following must be met:

Contrave prerequisites: A. Criteria A-D in Initial Approval Criteria are met; B. Negative history of uncontrolled hypertension, use of other bupropion-containing products, chronic opioid use, MAOI therapy during or within the last 14 days, seizure disorder, anorexia or bulimia, or abrupt discontinuation of alcohol, benzodiazepines, barbiturates, or antiepileptic drugs; C. Treatment protocol: initial approval 12 weeks up to 32 mg/360 mg per day (4 tablets per day); continued approval 6 months if patient has lost at least 5% of baseline body weight after initiating treatment, has a BMI ≥ 25, maintains initial weight loss, dose does not exceed 32 mg/360 mg per day, and continues to meet all above criteria.

Noradrenergic sympathomimetic drugs (e.g., phentermine, diethylpropion, benzphetamine, phendimetrazine)

In addition to Initial Approval Criteria, ALL of the following apply:

Sympathomimetics prerequisites: Contraindications include recent MAOI use (within 14 days), glaucoma, hyperthyroidism, history of drug abuse, and cardiac disease/uncontrolled hypertension per agent-specific language; treatment protocol: initial approval 12 weeks and total treatment duration limited to 12 weeks (short-term use).

This policy excludes agents that are not FDA‑approved for weight loss and has been updated historically to remove withdrawn products. Notably, Belviq (lorcaserin) and Belviq XR were removed from the policy following the FDA withdrawal from the market; see the revision history for dates and details of those changes. For full revision history, including additions and other removals, refer to the policy’s revision entries.

Use of pharmacologic weight loss agents is considered not medically necessary when the member does not meet the documented eligibility criteria — for example, BMI below 30 (or BMI below 27 without a qualifying comorbidity) — or when the member is not actively enrolled in a reduced‑calorie diet and increased physical activity weight loss program. Concurrent use of two weight loss medications is not permitted and such requests will be considered not medically necessary.

Prior Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for all weight loss agents. Initial approvals are typically issued for 12 weeks; continuation approvals are generally for 6 months when continuation criteria are met (specifics vary by agent).

Prior authorization required for all weight loss medications
Initial approval: 12 weeks (agent-specific dosing limits apply)
Continuation approval: commonly 6 months if continuation criteria met (see medication-specific criteria)

Documentation Required

Adjunct Weight Loss Program Requirement

Members must be actively enrolled in a structured weight loss program that includes a reduced-calorie diet and increased physical activity as an adjunct to pharmacotherapy. Enrollment documentation must be current at the time of request and during continuation reviews.

Active enrollment in a diet/exercise/behavior weight loss program required
Program must include reduced-calorie diet and increased physical activity
Enrollment must be documented and current for both initial and continuation requests

Documentation Required

Required Documentation

Required documentation must be submitted with the prior authorization request to demonstrate eligibility and medical necessity.

Current BMI (documented within the medical record)
Documentation of obesity-related comorbidities when BMI is ≥27 and <30 (e.g., hypertension, diabetes, dyslipidemia, cardiovascular disease, sleep apnea), or other obesity-related medical conditions
Evidence of active enrollment in a structured weight loss program (diet/exercise/behavior program)
Prior therapy notes: weight history, prior attempts at lifestyle modification, previous anti-obesity medications and outcomes
Age and indication consistent with FDA labeling for the requested medication

Denial Risk

Eligibility BMI and Program Enrollment

Eligibility is based on BMI thresholds and active program enrollment. Requests may be denied if BMI criteria are not met or if the member is not enrolled in an appropriate weight loss program.

Initial eligibility: BMI ≥ 30, OR BMI ≥ 27 with at least one obesity-related comorbidity
For certain pediatric indications (e.g., liraglutide), age and BMI/weight thresholds per policy must be met
Denial risk if BMI is below required thresholds or if documentation does not show active enrollment in a weight loss program

Denial Risk

No Concurrent Weight Loss Medications

Concurrent use of two weight loss medications is not permitted. Requests for overlapping therapy or for adding a second anti-obesity agent may be denied.

Member must NOT be receiving two medications for weight loss concurrently
Concurrent use may result in denial of the request

Formulations, Response Thresholds, and Codes

Formulations listed in policyNDC | mixed

120mg	Orlistat (Xenical) 120mg capsule
3.75/23,7.5/46,11.25/69,15/92	Phentermine/topiramate (Qsymia) ER capsule strengths
18mg/3ml	Liraglutide (Saxenda) pen injection
8/90	Naltrexone/bupropion (Contrave) 8mg/90mg ER tablet
25,50	Benzphetamine tablet strengths
35,105	Phendimetrazine tablet/ER capsule strengths
8,15,30,37.5	Phentermine tablet/capsule strengths (various)
25,75	Diethylpropion tablet/ER strengths

Weight loss response thresholds for continuation

Orlistat (Xenical) continuation thresholdContinued approval 6 months if member has lost at least 5% of initial body weight during the first 12 weeks, has a BMI ≥ 25, maintains initial weight loss, and dose ≤360 mg/day.

Phentermine/topiramate (Qsymia) continuation thresholdContinued approval 6 months (up to 15/92 mg/day) if member has lost at least 5% of initial weight during the first 12 weeks, has a BMI ≥ 25, maintains initial weight loss, and dose ≤15/92 mg/day.

Liraglutide (Saxenda) continuation threshold — adultsContinued approval 6 months (≤3 mg/day) if adult patient has lost at least 4% of baseline body weight after initiating treatment, has a BMI ≥ 25, maintains initial weight loss, and dose ≤3 mg/day.

Liraglutide (Saxenda) continuation threshold — pediatricsContinued approval 6 months if pediatric patient (12–18 yrs, >60 kg) has lost at least 1% of baseline BMI after initiating treatment, has a BMI ≥ 25, maintains initial weight loss, and dose ≤3 mg/day.

Naltrexone/Bupropion (Contrave) continuation thresholdContinued approval 6 months (≤32 mg/360 mg per day) if patient has lost at least 5% of baseline body weight after initiating treatment, has a BMI ≥ 25, maintains initial weight loss, and dose ≤32 mg/360 mg per day.

Phentermine and other sympathomimetics continuation policyInitial approval 12 weeks; total treatment duration for short‑term sympathomimetic agents is limited to 12 weeks (no prolonged continuation beyond initial period).

Policy Updates and Notes

2021-01-15Policy creation

Policy created as a new weight loss agents coverage policy (New policy, Approval Date 01/15).

2018-12-15Annual review (no clinical changes)

Annual review performed with no clinical policy statement changes noted (Annual review. No changes, Date = 12/15).

2017-07-01Approval update

Added Belviq XR to policy and standardized initial approval to 12 weeks with reauthorization at 6 months for most drugs; sympathomimetics limited to total 12 weeks and maximum continued doses added (Approval Date = 07/17).

2016-09-01Template conversion and edits

Converted to new template; removed language that weight loss agents are covered by respective health plans as they are covered by Medi‑Cal; removed non‑true contraindications and counseling‑only items; modified approval durations to reflect package inserts (Date = 09/16).

2019-04Removal of withdrawn agents and Saxenda/policy updates

Removed Belviq and Belviq XR from the policy due to FDA market withdrawal; for Saxenda added requirement that member not be on another GLP‑1 agonist and added pediatric indication and criteria; modified sympathomimetic contraindication language and other criteria updates (Date = 04/19; also reflected in 04/20 entries).

2020-04Criteria additions and refinementsLatest

Added elevated waist circumference and other obesity‑related conditions to initial criteria; removed negative pregnancy test requirement; clarified weight loss program must include diet and exercise; added Saxenda pediatric criteria and other reference updates (Approval Date = 04/20 / 03/21 entries).

OpenPayer

Weight Loss Agents

Medical Necessity and Agent-Specific Criteria

Prior Authorization and Documentation Requirements

Formulations, Response Thresholds, and Codes

Key Definitions and Comorbidities

Policy Rationale and Scope

Policy Updates and Notes