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    v1.0.30
    OpenPayerPolicy UpdatesClinical/Medical PolicyPacificSource Weight Loss Prior Auth | OpenPayer
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    CurrentPacificSourcePolicy CLB1249_0124

    Weight loss prior authorization criteria for select large groups

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    This policy governs prior authorization for weight loss medications for select large-group members whose coverage includes a weight-loss benefit. It defines eligible drugs, clinical criteria, required documentation, exclusions, prescribing and site-of-care requirements, benefit tiers, and approval duration.

    Policy Summary
    PayerPacificSource
    PolicyWeight loss prior authorization criteria for select large groups
    Policy CodePolicy CLB1249_0124
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit the drug name, dose, frequency, and member's current height and weight with the prior authorization request.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    10Named affected weight loss drugs
    BMI ≥30BMI threshold without listed risk factor
    BMI ≥27BMI threshold with listed risk factor
    12 monthsStandard approval duration
    Tier 3 / Tier 1Approved medication benefit tiers

    Eligibility and Coverage Requirements

    Initial therapy eligibility

    Covered for FDA-approved indications, including weight loss, when benefit design permits coverage and all required clinical information and treatment conditions are documented.

    Required coverage conditions

    • BMI eligibility

      • BMI ≥30: Body mass index is 30 or greater.BMI ≥30

      • BMI ≥27 with qualifying risk factor

        • At least one qualifying risk factor

          • Coronary heart disease.
    Policy Summary
    PayerPacificSource
    PolicyWeight loss prior authorization criteria for select large groups
    Policy CodePolicy CLB1249_0124
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit the drug name, dose, frequency, and member's current height and weight with the prior authorization request.
    SourceLink
    On This Page
    Eligibility and Coverage RequirementsClinical ThresholdsPrior Authorization and DocumentationPolicy Context

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Dyslipidemia demonstrated by HDL cholesterol less than 35 mg/dL, LDL cholesterol greater than or equal to 160 mg/dL, or triglycerides greater than or equal to 400 mg/dL.HDL <35 mg/dL OR LDL ≥160 mg/dL OR triglycerides ≥400 mg/dL
  1. Hypertension: Blood pressure is greater than 140/90.>140/90
  2. Obstructive sleep apnea.
  3. Type 2 diabetes mellitus.

    4. Reauthorization

    Reauthorization requires documented treatment success.

    Continuation therapy: A reduction in body weight from baseline is documented.Reduction in body weight from baseline

    Pregnancy is excluded from coverage.

    Over-the-counter (OTC) products are not covered.

    Coverage applies only to select large groups whose benefit includes weight-loss coverage. Member handbook provisions and other benefit design limitations apply. When approved, brand medications are covered at Tier 3 and generic medications at Tier 1.

    Clinical Thresholds

    BMI without additional risk factor
    Eligibility thresholdBMI of 30 or greater
    Additional risk factorNot required at this BMI threshold
    Covered useWeight loss under an FDA-approved indication, unless excluded by benefit design
    BMI with qualifying risk factor
    Eligibility thresholdBMI of at least 27
    Risk factor requirementAt least one qualifying risk factor must be present
    Covered useWeight loss under an FDA-approved indication, unless excluded by benefit design
    HDL cholesterol
    HDL cholesterol thresholdLess than 35 mg/dL
    Clinical categoryQualifying dyslipidemia risk factor
    BMI pathwayApplies with a BMI of at least 27
    LDL cholesterol
    LDL cholesterol thresholdGreater than or equal to 160 mg/dL
    Clinical categoryQualifying dyslipidemia risk factor
    BMI pathwayApplies with a BMI of at least 27
    Triglycerides
    Triglyceride thresholdGreater than or equal to 400 mg/dL
    Clinical categoryQualifying dyslipidemia risk factor
    BMI pathwayApplies with a BMI of at least 27
    Blood pressure
    Blood pressure thresholdGreater than 140/90
    Clinical categoryQualifying hypertension risk factor
    BMI pathwayApplies with a BMI of at least 27

    Prior Authorization and Documentation

    Prior Authorization

    Prior Authorization Required

    Submit a prior authorization request for weight-loss medications covered under this policy. The criteria apply to the listed drugs and any other medications approved by the U.S. Food and Drug Administration for weight loss, for select large groups with a weight-loss benefit.

    • Affected drugs include Adipex-P/Lomaira (phentermine), Contrave (naltrexone-bupropion), diethylpropion, phendimetrazine, Qsymia (phentermine-topiramate), Regimex (benzphetamine), Saxenda (liraglutide), Wegovy (semaglutide), Xenical (orlistat), and Zepbound (tirzepatide).
    • When approved, brand medications are covered at Tier 3 and generic medications at Tier 1.
    • Approval is generally for 12 months unless otherwise specified.
    Documentation Required

    Authorized Prescriber Required

    Weight-loss drugs must be ordered by a physician or another practitioner with prescriptive authority.

    Documentation Required

    Initial Request Information

    The initial request must identify the requested drug and provide the member’s current height and weight, along with the clinical information needed to establish coverage eligibility.

    • Drug name, dose, and frequency.
    • Current height and weight.
    • BMI of 30 or greater, or BMI of at least 27 with an applicable qualifying risk factor.
    • Qualifying risk factors may include coronary heart disease; dyslipidemia; hypertension with blood pressure greater than 140/90; obstructive sleep apnea; or type 2 diabetes mellitus.
    • For dyslipidemia, document HDL cholesterol less than 35 mg/dL, LDL cholesterol greater than or equal to 160 mg/dL, or triglycerides greater than or equal to 400 mg/dL.
    • Document use with caloric restriction, increased physical activity, and behavioral modification.
    Documentation Required

    Reauthorization Documentation

    Reauthorization requests must include documentation of treatment success, defined as a reduction in body weight from baseline.

    • Submit the member’s baseline weight and evidence of the subsequent reduction in body weight.
    Denial Risk

    Pregnancy Exclusion

    Coverage for weight-loss drugs is excluded during pregnancy.

    Denial Risk

    Over-the-Counter Products Not Covered

    Over-the-counter products will not be covered under this benefit.

    Denial Risk

    Required Clinical Eligibility

    A request may not meet coverage criteria if it does not document the required BMI threshold and, when applicable, a qualifying risk factor.

    • BMI of 30 or greater qualifies without an additional listed risk factor.
    • BMI of at least 27 requires documentation of at least one qualifying risk factor, such as coronary heart disease, dyslipidemia, hypertension, obstructive sleep apnea, or type 2 diabetes mellitus.
    Denial Risk

    Unsuccessful Continuation Therapy

    Continuation therapy requires documented treatment success. Requests without evidence of a reduction in body weight from baseline may not qualify for reauthorization.

    • Treatment must be used with caloric restriction, increased physical activity, and behavioral modification.
    • All approvals are subject to use of the most cost-effective site of care.

    Policy Context

    This policy addresses pharmacologic treatment of obesity and overweight for members whose benefit includes weight-loss coverage. Eligibility is based on BMI, with a lower threshold permitted when specified obesity-related or cardiovascular risk factors are present. Medication therapy must be used with caloric restriction (diet), increased physical activity, and behavioral modification.