Primary navigation

    Anti-Obesity Medications

    Drug - Anti-Obesity Medications

    March 2023

    Covered drugs with prior authorization:

    • Benzphetamine
    • Contrave
    • Diethylpropion or diethylpropion ER
    • Lomaira
    • Orlistat
    • Phendimetrazine or phendimetrazine ER
    • Phentermine capsules (Apidex-P and generics):  15mg, 30mg, 37.5mg
    • Phentermine tablets (Apidex-P and generics):  37.5mg
    • Saxenda
    • Wegovy
    • Xenical

    Initial approval criteria for covered drugs with prior authorization:

    • Patient must meet the age limit indicated in the FDA-approved label of the requested drug AND
    • Documentation of initiation of or ongoing reduced calorie diet; OR
    • Documentation of ongoing care of a registered dietitian nutritionist; AND
    • Documentation of initiation of or ongoing regimen of increased physical activity unless medically contraindicated by co-morbidity AND
    • Baseline body mass index (BMI) must be:
      • Greater than or equal to 30 kg/m2 with no risk factors (for patient at least 18 years of age) OR
      • Greater than or equal to 27 kg/m2 with at least one weight-related comorbid condition (e.g. hypertension, type 2 diabetes mellitus, or dyslipidemia) (for patient at least 18 years of age) OR
      • Greater than or equal to 30 kg/m2 and body weight above 60 kg (for patient 12 to 17 years of age) AND
    • Patient’s weight at baseline (in kg) must be submitted at time of request
    • No contraindications (disease state or current therapy) should exist unless the prescriber documents that benefits outweigh risks AND
    • No concurrent use of any other weight loss drug(s) AND
    • Initial approval is for:
      • 6 months for Saxenda, Wegovy, Contrave, Xenical or orlistat; and may be renewed if renewal criteria is met.  After lapses of therapy, additional trials may be approved if initial approval criteria is met.
      • 3 months for phentermine tablets and capsules, Lomaira, benzphetamine, diethylpropion or diethylpropion ER, phendimetrazine or phendimetrazine ER; and cannot be renewed.  After lapses of therapy, additional trials may be approved if initial approval criteria is met

    Renewal criteria for covered drugs with prior authorization:

    • Patient, at least 18 years of age, must have at least 5% weight loss during the initial approval period OR
    • Patient, 12 to 17 years of age, must have at least 5% reduction in baseline BMI during the initial approval period AND
    • Documentation of ongoing reduced calorie diet OR
    • Documentation of ongoing care of a registered dietitian nutritionist AND
    • Documentation of ongoing regimen of increased physical activity unless medically contraindicated by co-morbidity AND
    • No contraindications (disease state or current therapy) should exist, unless prescriber documents that benefits outweigh risks AND
    • Renewal approval is for 12 months
    • Subsequent renewal approval (beyond 18 months) requires meeting all renewal criteria and documentation that patient maintains weight loss achieved during the initial approval period

    Quantity limits

    Quantity limits pursuant to the FDA-approved label will apply.

    Questions?

    MHCP Provider Resource Center 651-431-2700 or 800-366-5411

    back to top