Prior authorization required for listed AOMs (see Table 1)

Prior authorization is required for all current and future dose forms of the anti‑obesity medications listed in Table 1; medication‑specific criteria including indication, age, and dosing limits are defined in Table 1.

• PA is required for Liraglutide (Saxenda), Semaglutide (Wegovy), Tirzepatide (Zepbound) and other Table 1 agents.
• Professional samples cannot be used to establish prior medication history; supporting documentation may be requested when claims history is insufficient.

Exemptions — specified older agents do not require PA

The following older agents are covered products and do not require prior authorization: benzphetamine, diethylpropion, phendimetrazine, naltrexone/bupropion, orlistat, phentermine, and phentermine/topiramate.

Preferred‑drug requirement — use preferred PDL agent unless non‑preferred criteria met

A preferred PDL drug that treats the PA indication must be used when applicable; a non‑preferred agent will only be approved if the patient meets the non‑preferred PDL prior‑authorization criteria.

Provide baseline weight/BMI and treatment plan with adjunct lifestyle intervention

Prescriber must provide the patient's baseline weight and BMI and submit a treatment plan that includes comprehensive adjunct lifestyle interventions (e.g., diet modification, physical activity, behavioral therapy).

• For drugs requiring a therapeutic dose (e.g., Wegovy, Saxenda), documentation that the patient can titrate to and maintain the therapeutic dose per FDA labeling is required.
• Professional samples are not allowed to establish medication history; supporting documentation may be required when claims history does not support prior use.

Exceptions to prior‑failure waiting periods — acceptable documentation and rationales

Exceptions to the 1‑year waiting period after failure of a Table 4 agent are allowed when documented: the patient was within 1% of the required weight loss for the failed agent and the requested agent is expected to be more efficacious per FDA labeling, or the patient was affected by a drug shortage (provide FDA or wholesaler report). Switching agents requires compelling rationale and is subject to review.

• Documentation required for shortage exceptions: FDA or pharmacy wholesaler report.
• Clinical rationale must show expected greater efficacy or that patient was within 1% of prior required weight loss.

Denial risks — missing FDA indication, thresholds, dosing, PDL, or baseline documentation

Denials are likely if the request does not meet FDA‑approved indication, age, weight/BMI or pediatric percentile thresholds, exceeds dosing limits in Table 1, does not use a preferred PDL when required, or if the prescriber fails to provide baseline weight/BMI and a comprehensive adjunct lifestyle treatment plan.

• For high‑cost (Table 4) agents, additional denial risks include not meeting the severe obesity definition (e.g., adults BMI <40 kg/m2) or lacking documentation of at least 3 months of lifestyle modification.
• Professional samples cannot be used to establish medication history — lack of supporting claims or documentation may result in denial.

High‑cost agent denial risks — severity, 3‑month lifestyle requirement, and prior‑failure timing

For high‑cost agents listed in Table 4, requests may be denied if the patient does not meet the severe obesity definition (Adults: BMI ≥40 kg/m2; Adolescents: ≥140% of the 95th percentile by age/sex or ≥40 kg/m2) or if there is insufficient documentation of at least 3 months of lifestyle modification. Previous failures to Table 4 agents require a minimum 1‑year waiting period before subsequent approval unless an approved exception is documented.

• Wegovy has a specific exception: adults with BMI ≥27 kg/m2 may qualify only if they have established CVD and do not have type I or II diabetes; T2DM patients must use a formulation indicated for T2DM.
• Length of initial approval differs: Zepbound (as of 4/1/24) and Wegovy (as of 6/1/25) = 28 weeks; other Table 4 agents = 8 weeks.