ModifiedPremera BluecrossPolicy N/A

Drugs for Weight Management (Pharmacy)

Criteria for medical necessity, authorization, and limits for pharmacy-covered medications used for chronic weight management and certain weight-related indications; intended for provider and pharmacy review.

Policy Summary

PayerPremera Bluecross

PolicyDrugs for Weight Management (Pharmacy)

Policy CodePolicy N/A

Change TypeMaterial updates to coverage criteria, dosing/quantity limits, and added agents/indications

Effective DateFeb 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization with documentation of baseline BMI, a ≥3-month trial of behavioral modification, and required prior generic trials when applicable.

SourceLink

POLICY UPDATE CHANGES

Added coverage criteria for Wegovy tablets to reduce the risk of major adverse CV events in adults with established cardiovascular disease and obesity or overweight.

Updated adult weight-related comorbid condition list to include asthma, COPD, coronary artery disease, knee osteoarthritis, metabolic-dysfunction associated steatotic liver disease/NAFLD, PCOS, and others.

Clarified that medications in this policy are subject to the product's FDA dosage and administration prescribing information and non-formulary exceptions may be approved up to 12 months.

Added Zepbound (tirzepatide) coverage criteria including use in certain individuals with moderate to severe obstructive sleep apnea and specified quantity limits (4 pens or vials per 30 days).

Added generic phentermine and generic phentermine/topiramate ER coverage criteria and required trial with generic phentermine/topiramate ER before Qsymia.

Updated quantity limits: Wegovy injection limited to 4 pens per 30 days; Saxenda and generic liraglutide 18 mg/3 mL pen limited to 5 pens per 30 days.

≥3 monthsBehavioral trial

≥30 or ≥27+comorbidityBMI threshold

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≥5% weight lossReauth threshold

12–17 eligiblePediatric approvals

4 pens/monthQty limit (injectables)

5 pens/monthSaxenda qty

Coverage Criteria — Drug-specific Initial and Indication Rules

inv-18: Zepbound re-authorization for chronic weight management and OSA

ALL of the following

Non-formulary exception reviews and all other reviews for Zepbound (tirzepatide) for chronic weight management in adults may be approved for 1 year when clinical benefit/response at the time of re-authorization show:
ALL of the following
- Weight loss of greater than or equal to 5% baseline body weight after 7 months of treatment>= 5%
- The individual is able to tolerate a Zepbound (tirzepatide) maintenance dose of up to 15 mg once weekly<= 15 mg once weekly
- Continues to adhere to a reduced-calorie diet and increased physical activity
Non-formulary exception reviews and all other reviews for Zepbound (tirzepatide) to treat moderate to severe obstructive sleep apnea (OSA) in adults may be considered medically necessary when all the following criteria are met:
ALL of the following
- The individual is aged 18 years or older
- At baseline, had a body mass index (BMI) of greater than or equal to 30 kg/m2>= 30 kg/m2
- Weight loss of greater than or equal to 10% baseline body weight after 12 months of treatment>= 10%
- Has stability in OSA signs or symptoms such as snoring, excessive daytime sleepiness, and fatigue
- Medication is being used as an adjunct to a reduced-calorie diet and increased physical activity
For OSA re-authorization: clinical documentation must demonstrate sustained weight loss (>= 10% baseline body weight after 12 months), stability of OSA signs/symptoms, and continued adherence to adjunctive lifestyle measures; approvals may be for up to 1 year when criteria are met.

Coding, BMI Thresholds and Trial Eligibility

Codingmixed

No codes listed

Body mass index (BMI) — Adult thresholds (≥30 or ≥27 + comorbidity)

Adult BMI thresholdsAdults: BMI >=30 kg/m2, or BMI >=27 kg/m2 with one or more specified weight‑related comorbid conditions (examples: asthma, cardiovascular disease, COPD, coronary artery disease, dyslipidemia, hypertension, knee osteoarthritis, MAFLD/NAFLD, obstructive sleep apnea, PCOS, type 2 diabetes)

Behavioral requirementTrial of behavioral modification and dietary restriction for at least 3 months required prior to initiation

Adjunctive useMedication must be used as an adjunct to a reduced‑calorie diet and increased physical activity

Age requirementMost adult indications require the individual to be aged 18 years or older

Example dose constraint tied to BMI rulesSome agents include dose or quantity limits tied to adult indications (see drug‑specific limits)

Prior Authorization, Documentation, Step Therapy and Denial Risks

Prior Authorization

Prior Authorization Required

Prior authorization is required for all drugs listed in this policy. Non‑formulary exception reviews for any medication in this policy may be approved for up to 12 months; other initial approvals vary by drug (see individual drug criteria).

Prior authorization required for listed weight‑management drugs
Non‑formulary exception reviews may be approved up to 12 months

Denial Risk

Coverage May Be Excluded by Benefit Plan

Drugs for weight management may be excluded under many benefit plans. Prior to prescribing, verify the member’s benefit plan for coverage of weight‑management medications (e.g., Contrave, Saxenda, Wegovy, Qsymia, Zepbound, Xenical).

Weight‑management drugs may be excluded under many benefit plans — confirm member benefits

Initial Authorization Prerequisites and Durations

Initial authorization durations

Initial authorization durations — approvals vary by agent; see specific drug nodes for dose and age criteria

Initial length note: Non-formulary exception reviews for all drugs may be approved up to 12 months; specific initial authorization durations differ by drug (e.g., Contrave other reviews 4 months; generic phentermine/topiramate and Qsymia 6 months; liraglutide pens and Saxenda 4 months; Wegovy 7 months for certain initial approvals).

See policy details

Initial therapy rules

Initial therapy rules — Covered when specified initial authorization intervals and non-formulary exception reviews are met

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Titration and initiation

Titration and initiation — trial-based titration schedules inform initiation

Re-authorization and Continuation Rules

Continuation / Re-authorization

Re-authorization criteria for continued coverage

General reauth requirement (Contrave): Non-formulary exception reviews and all other reviews for Contrave may be approved for 1 year when clinical benefit at re-authorization shows weight loss >=5% baseline body weight after 15 weeks of treatment and continued adherence to a reduced-calorie diet and increased physical activity>=5% at 15 weeks

General reauth requirement (phentermine/topiramate): Non-formulary exception reviews and all other reviews for generic phentermine and topiramate extended-release and Qsymia for adults may be approved for 1 year when clinical benefit at re-authorization shows weight loss >=5% baseline body weight after 26 weeks of treatment and continued adherence to a reduced-calorie diet and increased physical activity>=5% at 26 weeks

Wegovy and Zepbound reauth:

Step Therapy Requirements and Considerations

Drug / Requirement	Step therapy requirement	Supporting detail
Qsymia (phentermine/topiramate ER)
Prior trial of generic phentermine and topiramate extended-release required (inadequate response or intolerance)
Policy: Qsymia coverage requires the individual to have tried and had an inadequate response or intolerance to generic phentermine and topiramate extended-release; adult Qsymia criteria and trial requirement described in policy (see Qsymia coverage criteria).

Pathway	Description	Notes / Authorization impact
Non‑formulary exception review
Pathway allowing coverage consideration when standard formulary step requirements are not met
Non‑formulary exception reviews for drugs listed in this policy may be approved up to 12 months; specific clinical documentation and justification required per prior authorization rules.

Topic	Evidence summary	Implications / Alternatives
Orlistat (Xenical) clinical evidence
Randomized trials (including the 4‑year XENDOS study) demonstrated that orlistat produces greater mean percent weight loss versus placebo and reduces progression to type 2 diabetes; multiple trials showed higher proportions achieving ≥5% and ≥10% weight loss versus placebo.
Orlistat may be considered an alternative pharmacologic option in patients where step requirements or contraindications preclude use of other agents; GI adverse effects are common and should be discussed with patients.

Agent	Required prior trial	Policy note
Saxenda (liraglutide)
Trial of generic liraglutide 18 mg/3 mL pen required (inadequate response or intolerance)
Policy requires trial and inadequate response or intolerance to generic liraglutide pen before Saxenda may be considered; quantity limit for liraglutide pens is 5 pens/30 days.

Quantity and Dose Limits by Agent

Generic liraglutide 18 mg/3 mL pen — quantity limit (5 pens)

Quantity limitGeneric liraglutide 18 mg/3 mL pen — 5 pens per 30 days

Dose limit (maintenance)Dose limited to 3 mg per day per product rules

Usage contextUsed as adjunct to diet and increased physical activity; not to be used concurrently with other listed weight‑loss medications

Saxenda (liraglutide) — quantity limit (5 pens)

Quantity limitSaxenda (liraglutide) — 5 pens per 30 days

Dose limitDose limited to 3 mg per day; Saxenda requires prior trial/intolerance to generic liraglutide pen for adults

Background and Evidence Context

Excess body weight increases the risk of diabetes, hypertension, dyslipidemia, cardiovascular disease, and mortality. FDA‑approved pharmacologic agents are intended as adjuncts to a reduced‑calorie diet and increased physical activity for chronic weight management. Several agents in this policy have demonstrated efficacy in randomized trials and, for semaglutide (Wegovy), cardiovascular outcome data support a reduction in major adverse cardiovascular events in a population with established cardiovascular disease.

Definitions and Pediatric BMI Reference

Chronic weight management definition

DefinitionChronic weight management: pharmacologic treatment used in conjunction with reduced‑calorie diet and increased physical activity to achieve and maintain weight reduction, as studied in randomized trials

Trial contextPivotal trials paired medication with lifestyle counseling (reduced‑calorie diet and activity) beginning at first dose

Treatment intentIntended for long‑term weight reduction and maintenance rather than short‑term use alone

Weight-loss response definitions — percent reductions at timepoints

Weight‑loss response examplesCommon reauthorization thresholds include: ≥5% baseline body weight after agent‑specific intervals (examples: Contrave ≥5% at 15 weeks; Qsymia and generic phentermine/topiramate ≥5% at 26 weeks; Wegovy ≥5% after 7 months); liraglutide (Saxenda) uses ≥4% at 16 weeks

Policy Change Log

2026-02-01policy updateLatest

Added coverage criteria for Wegovy (semaglutide) tablets for MACE risk reduction in adults with established cardiovascular disease and obesity or overweight; updated Wegovy injection criteria to include Wegovy tablets among medications not to be used concurrently with other policy drugs.

2026-01-13interim review

Updated quantity limits: clarified Wegovy injection limited to 4 pens per 30 days, Saxenda and generic liraglutide pens limited to 5 pens per 30 days, and Zepbound limited to 4 pens or vials per 30 days.

Policy Summary

PayerPremera Bluecross

PolicyDrugs for Weight Management (Pharmacy)

Policy CodePolicy N/A

Change TypeMaterial updates to coverage criteria, dosing/quantity limits, and added agents/indications

Effective DateFeb 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization with documentation of baseline BMI, a ≥3-month trial of behavioral modification, and required prior generic trials when applicable.

SourceLink

On This Page

Pediatric BMI threshold — Age 12–17: BMI ≥95th percentile for age and sex

Pediatric BMI threshold (key)Age 12–17 years: BMI greater than or equal to the 95th percentile for age and sex (CDC appendix table)

Behavioral requirementTrial of behavioral modification and dietary restriction for at least 3 months required prior to initiation

Adjunctive useMedication must be used as an adjunct to a reduced‑calorie diet and increased physical activity

Age boundariesPediatric criteria apply to individuals aged between 12 and 17 years per drug‑specific nodes

Refer to appendixSee Appendix Table 1 for sex‑ and age‑specific BMI percentile cut‑offs for ages 12+

BMI or weight-loss thresholds — examples and response thresholds

Common trial/re‑auth response thresholdsWeight‑loss response thresholds referenced across agents: ≥5% baseline body weight at defined timepoints (examples: Wegovy ≥5% after 7 months; many agents require ≥5% at 15–26 weeks); some agents use ≥4% (liraglutide) or ≥10% for OSA reauthorization with tirzepatide

Shorter pediatric response measureFor pediatric Wegovy reauthorization: ≥1% baseline BMI after 7 months (pediatric-specific)

Dose‑tolerance requirementContinuation often requires ability to tolerate the FDA‑labeled maintenance dose (agent‑specific) at reauthorization

Examples of BMI eligibility used in trialsTrials enrolled adults with BMI ≥30 kg/m2 or BMI 27–29.9 kg/m2 with at least one weight‑related comorbidity

Documentation neededReauthorization requires documentation of clinical benefit/response and continued adherence to diet and activity

BMI eligibility referenced in trials — typical trial enrollment criteria

Typical trial enrollment BMIPivotal trials generally enrolled adults with BMI ≥30 kg/m2 or BMI 27–29.9 kg/m2 with at least one weight‑related comorbidity

Titration and maintenance periodsTrials included titration to maintenance (examples: Saxenda titrated to 3 mg daily over 4 weeks; Wegovy escalated to 2.4 mg weekly over 16 weeks; Zepbound titrated over ~20 weeks)

Study durations used to assess efficacyEfficacy assessed at timepoints such as 56–72 weeks with maintenance periods of at least 52 weeks in many trials

Lifestyle intervention in trialsAll pivotal trials paired medication with reduced‑calorie diet (~500 kcal/day deficit) and increased physical activity counseling

Examples: Contrave, Saxenda, Wegovy, Qsymia, Zepbound, Xenical

Billing Rule

Concurrent Therapy and Quantity/Dose Limits

Concurrent use of more than one medication intended for weight loss, or exceeding specified dose/quantity limits, will trigger a denial. Examples of prohibited concurrent medications include generic phentermine, generic phentermine/topiramate ER, benzphetamine, diethylpropion, phendimetrazine, Alli (orlistat), Contrave, liraglutide 18 mg/3 mL pen, Qsymia, Saxenda, Wegovy injection, Xenical, and Zepbound.

Concurrent therapy with other weight‑loss medications is not permitted and may be denied
Quantity and dose limits in individual drug criteria must be followed

Denial Risk

Qsymia Pregnancy Contraindication

Qsymia is contraindicated in pregnancy and will be denied for pregnant individuals. Topiramate (a component of Qsymia) is associated with increased risk of oral clefts with first‑trimester exposure; fetal harm has been observed in animal studies.

Qsymia contraindicated in pregnancy — use may cause fetal harm
Increased risk of oral clefts with first‑trimester topiramate exposure

Denial Risk

Concurrency Restriction with Generic Phentermine/Topiramate ER

Concurrent use of generic phentermine/topiramate extended‑release with other policy‑listed weight‑loss medications is not permitted and may trigger denial of authorization.

No concurrent use of generic phentermine/topiramate ER with other policy‑listed agents
Concurrent‑use denials may be applied at claim review

Documentation Required

Required Medical Record Documentation

Medical records submitted for prior authorization and reauthorization must document that the medical necessity criteria are met. Records should include baseline body weight, BMI, relevant medical history including weight‑related comorbidities, a documented dietary plan and physical activity plan, office visit notes, and medication dosing.

Include baseline body weight and BMI
Document weight‑related comorbidities and relevant history
Provide dietary and physical activity plan and office visit notes
Include prescribed medication name, dose, and quantity

Note

Step Considerations (Informational)

Step therapy considerations: orlistat has evidence supporting use as an alternative step option in some patients; individual drug criteria outline preferred trial sequences (informational). Review step options and clinical appropriateness before requesting non‑formulary exceptions.

Orlistat (Xenical) may be an informational alternative step option
Check individual drug criteria for preferred step sequences before requesting exceptions

Step Therapy

Step Therapy Requires Specified Generic Trials

Step therapy requirements: Qsymia requires a prior trial and inadequate response or intolerance to generic phentermine and topiramate extended‑release before approval. Saxenda requires a trial with generic liraglutide 18 mg/3 mL pen prior to coverage of brand Saxenda. Follow the specified trial durations and reauthorization response thresholds in the policy.

Qsymia: trial of generic phentermine/topiramate ER with inadequate response or intolerance required
Saxenda: trial of generic liraglutide 18 mg/3 mL pen required
Adhere to trial durations and reauthorization weight‑loss thresholds per policy

Agent-specific titration facts: Saxenda titrated to 3 mg daily over 4 weeks; Wegovy escalated to 2.4 mg weekly over 16 weeks; Zepbound titrated to 5/10/15 mg weekly over 20 weeks; many trials paired titration with lifestyle counseling.

Titration schedules differ by agent and influence tolerability and discontinuation.

Initial therapy prerequisites

behavioral modification trial: Initial authorization typically requires documented trial of behavioral modification and dietary restriction (at least 3 months for many indications; pediatric requirements may be shortened to 3 months per updates).

All other reviews for Wegovy and Zepbound may be approved for 12 months when re-authorization criteria referenced elsewhere are met

Continuation / Re-authorization rules

Re-authorization rules — documented weight-loss response and continued adherence required; maintenance dose tolerance often required

Contrave continuation: Weight loss >=5% baseline body weight after 15 weeks; continues diet and activity.

Qsymia continuation (adult): Weight loss >=5% baseline body weight after 26 weeks; continues diet and activity.

Liraglutide continuation (adult): Weight loss >=4% baseline body weight after 16 weeks and able to tolerate maintenance dose of 3 mg once daily; continues diet and activity.

Wegovy continuation: Weight loss >=5% baseline body weight after 7 months and able to tolerate maintenance dose; continues diet and activity.

Zepbound continuation: Weight loss >=5% baseline body weight after 7 months and able to tolerate maintenance dose up to 15 mg weekly; continues diet and activity.

Continuation therapy notes

Continuation considerations reflect trial maintenance periods and discontinuation rates

Continuation supportive facts: Trials included maintenance dosing after titration periods (examples: Qsymia 56 weeks, Saxenda 56 weeks with maintenance at 3 mg, Wegovy 68 weeks with 52-week maintenance, Zepbound 72 weeks with maintenance); discontinuation due to adverse reactions occurred early for several agents, especially GI events.

Monitor tolerability and adverse reactions; many discontinuations occurred during titration.

Re-authorization criteria

Re-authorization criteria depend on drug-specific weight loss thresholds and differ by age group

re-auth overview: Re-authorization criteria: for adults weight loss percent is from baseline body weight; for pediatric individuals weight loss percent is from baseline BMI; specific thresholds vary by drug as stated in policy.

Pediatric Saxenda requires prior trial of generic liraglutide 18 mg/3 mL pen per policy

Wegovy (semaglutide) injection — quantity limit (4 pens)

Quantity limitWegovy (semaglutide) injection — 4 pens per 30 days

Dose/maintenanceDose limited to 2.4 mg once weekly for maintenance

Pediatric correctionPediatric Wegovy quantity corrected in history notes; pediatric dosing/quantity differ per pediatric node

Wegovy (semaglutide) tablets — quantity limit (1 tablet)

Quantity limitWegovy (semaglutide) tablets — 1 tablet daily (quantity limited to 1 tablet per day)

Dose limitDose limited to 25 mg daily for tablet formulation when indicated

MACE indicationTablets may be used for MACE risk reduction in adults with established CVD when criteria met

Zepbound (tirzepatide) — quantity limit (4 pens or vials)

Quantity limitZepbound (tirzepatide) — 4 pens or vials per 30 days

Dose limitDose limited to up to 15 mg once weekly (maintenance cap) for chronic weight management and OSA criteria specify 15 mg weekly

OSA-specific documentationOSA indication requires recent sleep study (AHI ≥15/hr) and exclusion of central sleep apnea/CS respiration

Xenical (orlistat) — quantity limit (3 capsules)

Quantity limitXenical (orlistat) — three 120 mg capsules daily (3 capsules/day)

Dose scheduleTaken as one 120 mg capsule three times a day

Pediatric noteSame 3‑capsule daily dose limit applies for pediatric authorization nodes when approved

Contrave / Qsymia / generic phentermine/topiramate — varied dose limits noted (examples)

Examples of varied dose limitsContrave: limited to four 8 mg/90 mg tablets per day; Qsymia and generic phentermine/topiramate ER: limited to one 15 mg/92 mg capsule daily

Concurrent use prohibitionThese agents must not be used concurrently with other policy‑listed weight‑loss medications

Pediatric dosing parallelsPediatric formulations (e.g., phentermine/topiramate ER) use the same 15 mg/92 mg daily capsule limit when authorized for ages 12–17

Injectable weekly agents (example: Zepbound, Wegovy) — quantity limit 4 pens or vials per 30 days

Quantity limit (monthly)Injectable weekly agents (examples: Zepbound, Wegovy) — limited to 4 pens or vials per 30 days

Maintenance dose examplesWegovy maintenance 2.4 mg weekly; Zepbound maintenance up to 15 mg weekly per labeled dosing

Not concurrentInjectable weekly agents must not be used concurrently with other medications intended for weight loss

Wegovy tablets — quantity limit (1 tablet)

Quantity limitWegovy tablets — 1 tablet daily (quantity limited to 1 tablet per day)

Dose limitDose limited to 25 mg daily for tablet formulation when indicated for weight management or MACE

Concurrent use prohibitionNot to be used concurrently with other listed weight‑loss medications

Agent-specific dosing — examples (Saxenda 3 mg daily, Wegovy 2.4 mg weekly, Zepbound up to 15 mg weekly)

Agent dosing examplesSaxenda: 3 mg once daily (titrated over 4 weeks); Wegovy injection: 2.4 mg once weekly maintenance (escalated over ~16 weeks); Zepbound: up to 15 mg once weekly maintenance (titrated over ~20 weeks)

Dose linked to labelingMaintenance dosing and titration schedules follow FDA‑labeled regimens used in pivotal trials

Dose tolerability for reauthReauthorization requires ability to tolerate the maintenance dose for many agents

Wegovy injection — quantity limit (4) (reconfirmed)

Quantity limit (reconfirmed)Wegovy injection — 4 pens per 30 days

Dose limitMaintenance dose limited to 2.4 mg once weekly

Pediatric correction notedPolicy history notes a minor pediatric quantity correction for Wegovy; pediatric quantity/dose addressed in pediatric nodes

Saxenda and generic liraglutide 18 mg/3 mL pen — quantity limit (5) (reconfirmed)

Quantity limit (reconfirmed)Saxenda (liraglutide) and generic liraglutide 18 mg/3 mL pen — 5 pens per 30 days

Dose limitDose limited to 3 mg per day for liraglutide products

Prior‑trial requirementSaxenda requires prior trial/intolerance to generic liraglutide pen for adult coverage

Zepbound (tirzepatide) — quantity limit (4) (reconfirmed)

Quantity limit (reconfirmed)Zepbound (tirzepatide) — 4 pens or vials per 30 days

Dose limitMaintenance dose limited to up to 15 mg once weekly

OSA noteOSA initial and reauthorization nodes reference the same 4‑pen/30‑day quantity and 15 mg weekly dose cap

Wegovy (pediatric) quantity — pediatric quantity correction noted

Pediatric Wegovy quantity notePolicy history documents a corrected pediatric quantity limit for Wegovy; pediatric nodes specify dose and quantity separately from adult limits

Refer to pediatric nodeSee Wegovy pediatric coverage criteria for age 12–17 which include BMI ≥95th percentile and quantity limited to 4 pens per 30 days when authorized

History entryMinor pediatric quantity correction noted in 06/01/23 review

Site of care — injectables given subcutaneously in outpatient settings

Site of careAll agents were administered in outpatient trial settings; injectable agents were given by subcutaneous administration in outpatient settings

Home administrationPer labeling and trial designs, some injectable agents may be administered in outpatient or home settings subcutaneously

Documentation implicationPrior authorization should verify outpatient administration plan consistent with product labeling and trial contexts

Pediatric threshold example

Pediatric Wegovy reauth: ≥1% baseline BMI after 7 months; Xenical pediatric reauth: ≥5% baseline BMI after 6 months

Dose tolerabilityReauthorization generally requires ability to tolerate the maintenance dose and continued adherence to diet and activity

Chronic weight management — pharmacologic treatment used with diet/exercise

DefinitionPharmacologic treatment used with reduced‑calorie diet and increased physical activity to achieve and maintain weight reduction (chronic weight management)

Clinical trial evidenceEfficacy and safety established in randomized trials with 56–72 week endpoints paired with lifestyle interventions

Provider requirementInitiation and continuation require documentation of lifestyle intervention and ongoing adherence

BMI percentiles for pediatric obesity (CDC criteria) — appendix table reference for ages 12+

CDC pediatric BMI percentilesBMI percentiles for pediatric obesity (CDC criteria) are provided in the Appendix Table 1 for individuals aged 12 years and older (e.g., 95th percentile values by age/sex listed in appendix)

Use in policyPolicy references the appendix 95th percentile cutoffs for pediatric authorization decisions (ages 12–17)

Appendix locationSee Appendix Table 1 for sex‑ and age‑specific BMI cutoffs used to define pediatric obesity from age 12 upwards

Updated Saxenda coverage criteria to require trial with generic liraglutide 18 mg/3 mL pen and added generic liraglutide 18 mg/3 mL pen coverage criteria for certain individuals with overweight or obesity.

2025-07-08interim review

Added generic phentermine and generic phentermine/topiramate extended-release coverage criteria and updated Qsymia coverage to require prior trial with the generic formulation.

2025-06-01annual review

Updated adult weight-related comorbid condition list (expanded to include asthma, COPD, coronary artery disease, knee osteoarthritis, MAFLD/NAFLD, PCOS, and others); clarified FDA dosing/administration compliance and non-formulary exception approvals up to 12 months; added Zepbound coverage including OSA indication.

2023-06-01annual review

Added Zepbound (tirzepatide) to the policy for chronic weight management and made a minor correction to the pediatric quantity limit for Wegovy.