Pharmacy Prior Authorization Criteria

Non-GLP-1 Agonist Anorexiants – PA, NF

Indications for Prior Authorization

Generic phentermine, Adipex-P (phentermine), Lomaira (phentermine)

• For diagnosis of Short-term Weight Reduction
  Indicated as a short-term (a few weeks) adjunct in a regimen of weight reduction based on exercise, behavioral modification, and caloric restriction in the management of exogenous obesity for patients with an initial body mass index (BMI) greater than or equal to 30 kg/m2, or greater than or equal to 27 kg/m2 in the presence of other risk factors (e.g., controlled hypertension, diabetes, hyperlipidemia).

Contrave (naltrexone/bupropion)

• For diagnosis of Chronic Weight Management
  Indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial BMI of greater than or equal to 30 kg/m2 (obese) or greater than or equal to 27 kg/m2 (overweight) in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia).

Qsymia (phentermine and topiramate)

• For diagnosis of Chronic Weight Management
  Indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in: 1) Adult patients with an initial BMI of greater than or equal to 30 kg/m2 (obese) or greater than or equal to 27 kg/m2 (overweight) in the presence of at least one weight-related comorbidity (e.g., hypertension, Page 1805 type 2 diabetes mellitus, dyslipidemia). 2) Pediatric patients aged 12 years and older with an initial BMI in the 95th percentile or greater standardized for age and sex.

Xenical (orlistat)

• For diagnosis of Obesity Management
  Indicated for obesity management including weight loss and weight maintenance when used in conjunction with a reduced-calorie diet. Xenical is also indicated to reduce the risk for weight regain after prior weight loss. Xenical is indicated for obese patients with an initial BMI greater than or equal to 30 kg/m2 or greater than or equal to 27 kg/m2 in the presence of other risk factors (e.g., hypertension, diabetes, dyslipidemia).

Criteria

Generic phentermine

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s)

• Treatment is being requested for appetite suppression or weight loss
AND
• One of the following:
• Both of the following:
• Patient is greater than 16 years of age
• Baseline BMI greater than or equal to 40 kg/m2 prior to initiating therapy
OR
• All of the following:
• Patient is greater than 16 years of age
AND
• Used as an adjunct to lifestyle modification (e.g., dietary or caloric restriction, exercise, behavioral support, community based program)
AND
• One of the following:
• Baseline BMI greater than or equal to 30 kg/m2 prior to initiating therapy
OR
• Both of the following:
• Baseline BMI greater than or equal to 27 kg/m2 prior to initiating therapy
• Patient has a weight-related comorbidity (e.g., hypercholesterolemia, hypertension, diabetes, sleep apnea)

Generic phentermine

Prior Authorization (Reauthorization)

Length of Approval: 6 Month(s)

• Weight loss of greater than or equal to 5% of baseline body weight [C]

Generic phentermine, Lomaira*, Brand Adipex-P*

*Please consult client-specific resources to confirm whether benefit exclusions should be reviewed for medical necessity.

Non Formulary (Initial Authorization)

Length of Approval: 6 Month(s)

• Treatment is being requested for appetite suppression or weight loss
AND
• One of the following:
• Both of the following:
• Patient is greater than 16 years of age
• Baseline BMI greater than or equal to 40 kg/m2 prior to initiating therapy
OR
• All of the following:
• Patient is greater than 16 years of age
AND
• Patient must have one or more of the following cardiovascular-related comorbidities[D]:
• Hypercholesterolemia
• Hypertension
• Type 2 diabetes mellitus
• Obstructive sleep apnea
• Cardiovascular disease
AND
• Patient’s baseline weight and BMI prior to initiating therapy is provided
AND
• Submission of medical records (e.g., chart notes) documenting baseline BMI greater than or equal to 35 kg/m2 prior to initiating therapy [8]
AND
• Submission of medical records (e.g., chart notes) documenting both of the following:
• Trial of lifestyle modification that promotes a reduced calorie diet and exercise of at least 150 minutes per week for at least 6 months and patient has failed to achieve adequate weight loss
• Patient will be using therapy with continued lifestyle modification that promotes a reduced calorie diet and exercise of at least 150 minutes per week
AND
• Submission of medical records (e.g., chart notes) or absence of paid claims within the past 90 days confirming medication is not being co-administered with any of the following:
• GLP-1 receptor agonists (e.g., Victoza, Ozempic, Rybelsus, Trulicity, Wegovy)
• Tirzepatide-containing products (e.g., Mounjaro)
• Other weight loss agents indicated for short-term weight reduction or chronic weight management (e.g., Qsymia, Contrave)
AND
• Provider attests to discontinuing or lowering the dose of drugs that may contribute to weight gain when clinically appropriate (e.g., neuropathic pain medications [gabapentin], antipsychotic medications [olanzapine], corticosteroids, hormonal therapy [estrogen replacement therapy])
AND
• One of the following:
• If the requested drug has a formulary alternative with the same active ingredient, both of the following:
• Submission of medical records (e.g., chart notes) documenting the patient has experienced intolerance (e.g., allergy to excipient) with a formulary alternative that has the same active ingredient
AND
• Submission of medical records (e.g., chart notes) or paid claims documenting the patient has tried and failed at least 2 additional formulary alternatives within the same therapeutic class. If only 1 formulary alternative within the therapeutic class is available, the patient must have tried the formulary alternative within the therapeutic class AND 1 additional formulary alternative. If there are no formulary alternatives within the same therapeutic class, the patient must have failed or had contraindication or intolerance to 2 formulary alternatives.
OR
• No formulary alternative is available to treat the patient's condition
AND
• Prescribed by a Healthcare Professional knowledgeable about the use of non-GLP-1s for chronic weight management who will be overseeing the treatment and monitoring of the patient
AND
• Medication is NOT prescribed by the following practitioners:
• Chiropractor
• Physical Therapist
• Ophthalmologist
• Social Worker
• Nurse Midwife
• Dentist
• Acupuncturist
• Audiologist
• Fitness Trainer
• Anesthesiologist
• Counselor
• Dermatologist
• Registered Dietician
• Therapist
• Pathologist
• Podiatrist
• Urologist

Generic phentermine, Lomaira, Brand Adipex-P

^PA clinician to confirm weight loss using the patient's baseline and current weight.

Non Formulary (Reauthorization)

Length of Approval: 6 Month(s)

• Patient's baseline and current weight and BMI is provided
AND
• Submission of medical records (e.g., chart notes) confirming weight loss of greater than or equal to 5% of baseline body weight^
AND
• Submission of medical records (e.g., chart notes) documenting that patient will be using therapy with continued lifestyle modification that promotes a reduced calorie diet and exercise of at least 150 minutes per week
AND
• Submission of medical records (e.g., chart notes) or absence of paid claims within the past 90 days confirming medication is not being co-administered with any of the following:
• GLP-1 receptor agonists (e.g., Victoza, Ozempic, Rybelsus, Trulicity, Wegovy)
• Tirzepatide-containing product (e.g., Mounjaro)
• Other weight loss agents indicated for short-term weight reduction or chronic weight management (e.g., Qsymia, Contrave)
AND
• Provider attests to discontinuing or lowering the dose of drugs that may contribute to weight gain when clinically appropriate (e.g., neuropathic pain medications [gabapentin], antipsychotic medications [olanzapine], corticosteroids, hormonal therapy [estrogen replacement therapy])
AND
• One of the following:
• If the requested drug has a formulary alternative with the same active ingredient, both of the following:
• Submission of medical records (e.g., chart notes) documenting the patient has experienced intolerance (e.g., allergy to excipient) with a formulary alternative that has the same active ingredient
AND
• Submission of medical records (e.g., chart notes) or paid claims documenting the patient has tried and failed at least 2 additional formulary alternatives within the same therapeutic class. If only 1 formulary alternative within the therapeutic class is available, the patient must have tried the formulary alternative within the therapeutic class AND 1 additional formulary alternative. If there are no formulary alternatives within the same therapeutic class, the patient must have failed or had contraindication or intolerance to 2 formulary alternatives.
OR
• No formulary alternative is available to treat the patient's condition
AND
• Prescribed by a Healthcare Professional knowledgeable about the use of non-GLP-1s for chronic weight management who will be overseeing the treatment and monitoring of the patient
AND
• Medication is NOT prescribed by the following practitioners:
• Chiropractor
• Physical therapist
• Ophthalmologist
• Social Worker
• Nurse Midwife
• Dentist
• Acupuncturist
• Audiologist
• Fitness Trainer
• Anesthesiologist
• Counselor
• Dermatologist
• Registered Dietician
• Therapist
• Pathologist
• Podiatrist
• Urologist

Qsymia*, Contrave*

*Please consult client-specific resources to confirm whether benefit exclusions should be reviewed for medical necessity.

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s) [A,B]

• Treatment is being requested for appetite suppression or weight loss
AND
• One of the following:
• Both of the following:
• Patient is 18 years of age or older OR patient is between 12 and 17 years of age (for Qsymia)
• Baseline BMI greater than or equal to 40 kg/m2 prior to initiating therapy
OR
• All of the following:
• Patient is 18 years of age or older
AND
• Used as an adjunct to lifestyle modification (e.g., dietary or caloric restriction, exercise, behavioral support, community based program)
AND
• One of the following:
• Baseline BMI greater than or equal to 30 kg/m2 prior to initiating therapy
OR
• Both of the following:
• Baseline BMI greater than or equal to 27 kg/m2 prior to initiating therapy
• Patient has a weight-related comorbidity (e.g., hypercholesterolemia, hypertension, diabetes, sleep apnea)
AND
• For Contrave Only: One of the following:
• Failure to lose greater than or equal to 3% of baseline body weight after 12 weeks of Qsymia therapy during initial dose escalation phase [A, C]
• Failure to lose greater than or equal to 5% of baseline body weight after an additional 12 weeks (24 weeks from baseline) of Qsymia therapy at highest strength [A, C]
• Intolerance or contraindication to Qsymia therapy
OR
• For Qysmia Only: All of the following:
• Patient is between 12 and 17 years of age
• Used as an adjunct to lifestyle modification (e.g., dietary or caloric restriction, exercise, behavioral support, community based program)
• Initial BMI is in the 95th percentile or greater standardized for age and sex

Qsymia, Contrave

Prior Authorization (Reauthorization)

Length of Approval: 6 Month(s)

• Weight loss of greater than or equal to 5% of baseline body weight or BMI [C]

Qsymia*, Xenical*, Orlistat*

*Please consult client-specific resources to confirm whether benefit exclusions should be reviewed for medical necessity.

Non Formulary (Initial Authorization)

Length of Approval: 6 Month(s) [A]
For diagnosis of Weight Management in Pediatric Patients between 12 and 17 years of age

• Treatment is being requested for appetite suppression or weight loss
AND
• One of the following:
• Both of the following:
• Patient is between 12 and 17 years of age
• Baseline BMI greater than or equal to 40 kg/m2 prior to initiating therapy
OR
• All of the following:
• Patient is between 12 and 17 years of age
AND
• Submission of medical records (e.g., chart notes) confirming patient’s initial BMI is in the 95th percentile or greater standardized for age and sex
AND
• Used as an adjunct to lifestyle modification (e.g., dietary or caloric restriction, exercise, behavioral support, community based program)
AND
• Submission of medical records (e.g., chart notes) or absence of paid claims within the past 90 days confirming medication is not being co-administered with any of the following:
• Tirzepatide-containing products (e.g., Mounjaro)
• GLP-1 receptor agonists (e.g., Ozempic, Rybelsus, Trulicity, Wegovy)
AND
• Prescribed by a Healthcare Professional knowledgeable about the use of non-GLP-1s for chronic weight management who will be overseeing the treatment and monitoring of the patient
AND
• Medication is NOT prescribed by the following practitioners:
• Chiropractor
• Physical therapist
• Ophthalmologist
• Social Worker
• Nurse Midwife
• Dentist
• Acupuncturist
• Audiologist
• Fitness Trainer
• Anesthesiologist
• Counselor
• Dermatologist
• Registered Dietician
• Therapist
• Pathologist
• Podiatrist
• Urologist

Qsymia, Xenical, Orlistat

Non Formulary (Reauthorization)

Length of Approval: 6 Month(s)
For diagnosis of Weight Management in Pediatric Patients between 12 and 17 years of age

• Patient is between 12 and 17 years of age
AND
• Submission of medical records (e.g., chart notes) confirming weight loss greater than or equal to 5% of baseline body weight
AND
• Submission of medical records (e.g., chart notes) or absence of paid claims within the past 90 days confirming medication is not being co-administered with any of the following:
• Tirzepatide-containing products (e.g., Mounjaro)
• GLP-1 receptor agonists (e.g., Ozempic, Rybelsus, Trulicity, Wegovy)
AND
• Prescribed by a Healthcare Professional knowledgeable about the use of non-GLP-1s for chronic weight management who will be overseeing the treatment and monitoring of the patient
AND
• Medication is NOT prescribed by the following practitioners:
• Chiropractor
• Physical therapist
• Ophthalmologist
• Social Worker
• Nurse Midwife
• Dentist
• Acupuncturist
• Audiologist
• Fitness trainer
• Anesthesiologist
• Counselor
• Dermatologist
• Registered Dietician
• Therapist
• Pathologist
• Podiatrist
• Urologist

Qsymia*, Contrave*, Xenical*, Orlistat*

*Please consult client-specific resources to confirm whether benefit exclusions should be reviewed for medical necessity.

Non Formulary (Initial Authorization)

Length of Approval: 6 Month(s)

• Treatment is being requested for appetite suppression or weight loss
AND
• One of the following:
• Both of the following:
• Patient is 18 years of age or older
• Baseline BMI greater than or equal to 40 kg/m2 prior to initiating therapy
OR
• All of the following:
• Patient is 18 years of age or older
AND
• Patient must have one or more of the following cardiovascular-related comorbidities[D]:
• Hypercholesterolemia
• Hypertension
• Type 2 diabetes mellitus
• Obstructive sleep apnea
• Cardiovascular disease
AND
• Patient’s baseline weight and BMI prior to initiating therapy is provided
AND
• Submission of medical records (e.g., chart notes) documenting baseline BMI greater than or equal to 35 kg/m2 prior to initiating therapy [8]
AND
• Submission of medical records (e.g., chart notes) documenting both of the following:
• Trial of lifestyle modification that promotes a reduced calorie diet and exercise of at least 150 minutes per week for at least 6 months and patient has failed to achieve adequate weight loss
• Patient will be using therapy with continued lifestyle modification that promotes a reduced calorie diet and exercise of at least 150 minutes per week
AND
• Submission of medical records (e.g., chart notes) or absence of paid claims within the past 90 days confirming medication is not being co-administered with any of the following:
• GLP-1 receptor agonists (e.g., Victoza, Ozempic, Rybelsus, Trulicity, Wegovy)
• Tirzepatide-containing products (e.g., Mounjaro)
• Other weight loss agents indicated for short-term weight reduction or chronic weight management (e.g., phentermine)
AND
• Provider attests to discontinuing or lowering the dose of drugs that may contribute to weight gain when clinically appropriate (e.g., neuropathic pain medications [gabapentin], antipsychotic medications [olanzapine], corticosteroids, hormonal therapy [estrogen replacement therapy])
AND
• One of the following:
• If the requested drug has a formulary alternative with the same active ingredient, both of the following:
• Submission of medical records (e.g., chart notes) documenting the patient has experienced intolerance (e.g., allergy to excipient) with a formulary alternative that has the same active ingredient
AND
• Submission of medical records (e.g., chart notes) or paid claims documenting the patient has tried and failed at least 2 additional formulary alternatives within the same therapeutic class. If only 1 formulary alternative within the therapeutic class is available, the patient must have tried the formulary alternative within the therapeutic class AND 1 additional formulary alternative. If there are no formulary alternatives within the same therapeutic class, the patient must have failed or had contraindication or intolerance to 2 formulary alternatives
OR
• If formulary alternatives are available and do not meet above scenarios, submission of medical records (e.g., chart notes) or paid claims documenting patient has tried and failed, or has contraindication or intolerance to at least 3 formulary alternatives. If only 1 or only 2 alternatives are available, the patient must have failed or had contraindications or intolerance to all available formulary alternatives
OR
• If only over-the-counter (OTC) equivalents^ are available, patient has tried and failed or has contraindications or intolerance to 3 OTC equivalents. If only 1 or only 2 equivalents are available, the patient must have failed or had contraindications or intolerance to all available OTC equivalents [document drug(s), dose, duration of trial]
OR
• No formulary alternative is available to treat the patient's condition
AND
• Prescribed by a Healthcare Professional knowledgeable about the use of non-GLP-1s for chronic weight management who will be overseeing the treatment and monitoring of the patient
AND
• Medication is NOT prescribed by the following practitioners:
• Chiropractor
• Physical Therapist
• Ophthalmologist
• Social Worker
• Nurse Midwife
• Dentist
• Acupuncturist
• Audiologist
• Fitness Trainer
• Anesthesiologist
• Counselor
• Dermatologist
• Registered Dietician
• Therapist
• Pathologist
• Podiatrist
• Urologist

Qsymia, Contrave, Xenical, Orlistat

^PA clinician to confirm weight loss using the patient's baseline and current weight. *OTC equivalents refers to any covered or non-covered OTC equivalent product.

Non Formulary (Reauthorization)

Length of Approval: 6 Month(s)

• Patient is 18 years of age or older
AND
• Patient’s baseline and current weight and BMI is provided
AND
• Submission of medical records (e.g., chart notes) confirming weight loss of greater than or equal to 5% of baseline body weight^
AND
• Submission of medical records (e.g., chart notes) documenting that patient will be using therapy with continued lifestyle modification that promotes a reduced calorie diet and exercise of at least 150 minutes per week
AND
• Submission of medical records (e.g., chart notes) or absence of paid claims within the past 90 days confirming medication is not being co-administered with any of the following:
• GLP-1 receptor agonists (e.g., Victoza, Ozempic, Rybelsus, Trulicity, Wegovy)
• Tirzepatide-containing products (e.g., Mounjaro)
• Other weight loss agents indicated for short-term weight reduction or chronic weight management (e.g., Phentermine)
AND
• Provider attests to discontinuing or lowering the dose of drugs that may contribute to weight gain when clinically appropriate (e.g., neuropathic pain medications [gabapentin], antipsychotic medications [olanzapine], corticosteroids, hormonal therapy [estrogen replacement therapy])
AND
• One of the following:
• If the requested drug has a formulary alternative with the same active ingredient, both of the following:
• Submission of medical records (e.g., chart notes) documenting the patient has experienced intolerance (e.g., allergy to excipient) with a formulary alternative that has the same active ingredient
AND
• Submission of medical records (e.g., chart notes) or paid claims documenting the patient has tried and failed at least 2 additional formulary alternatives within the same therapeutic class. If only 1 formulary alternative within the therapeutic class is available, the patient must have tried the formulary alternative within the therapeutic class AND 1 additional formulary alternative. If there are no formulary alternatives within the same therapeutic class, the patient must have failed or had contraindication or intolerance to 2 formulary alternatives.
OR
• If formulary alternatives are available and do not meet above scenarios, submission of medical records (e.g., chart notes) or paid claims documenting patient has tried and failed, or has contraindication or intolerance to at least 3 formulary alternatives. If only 1 or only 2 alternatives are available, the patient must have failed or has contraindications or intolerance to all available formulary alternatives
OR
• If only over-the-counter (OTC) equivalents* are available, patient has tried and failed or has contraindications or intolerance to 3 OTC equivalents. If only 1 or only 2 equivalents are available, the patient must have failed or had contraindications or intolerance to all available OTC equivalents [document drug(s), dose, duration of trial]
OR
• No formulary alternative is available to treat the patient's condition
AND
• Prescribed by a Healthcare Professional knowledgeable about the use of non-GLP-1s for chronic weight management who will be overseeing the treatment and monitoring of the patient
AND
• Medication is NOT prescribed by the following practitioners
• Chiropractor
• Physical therapist
• Ophthalmologist
• Social Worker
• Nurse Midwife
• Dentist
• Acupuncturist
• Audiologist
• Fitness Trainer
• Anesthesiologist
• Counselor
• Dermatologist
• Registered Dietician
• Therapist
• Pathologist
• Podiatrist
• Urologist

P & T Revisions

2025-01-22, 2024-12-20

References

1. Adipex-P Prescribing Information. Teva Pharmaceuticals USA, Inc. Parsippany, NJ . September 2020.
2. Xenical Prescribing Information. CHEPLAPHARM Arzneimittel GmbH. Greifswald, Germany. November 2020.
3. Qsymia Prescribing Information. Vivus, Inc. Campbell, CA. June 2022.
4. Lomaira Prescribing Information. KVK-Tech, Inc. Newtown, PA. December 2018.
5. Contrave Prescribing Information. Nalpropion Pharmaceuticals, Inc. La Jolla, CA. October 2020.
6. Orlistat Prescribing Information. H2-Pharma, LLC. Montgomery, AL. June 2022
7. Apovian MC, et al. Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. 2015; 100(2): 342-362.
8. Eisenberg D, Shikora SA, Aarts E, et al. 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for Metabolic and Bariatric Surgery. Surg Obes Relat Dis. 2022;18(12):1345-1356.

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End Notes

1. A. A patient receiving Qsymia should have two evaluation points - after 12 weeks, followed by another 12 weeks. During the first evaluation point, patient may be dose escalated. During the second evaluation, if the patient has not yet reached goal, it is recommended to discontinue Qsymia as directed. Therefore, a 6 month authorization duration is necessary to evaluate the patient adequately before determining efficacy. [3]
2. A patient receiving Contrave is recommended to be evaluated by week 12 at the maintenance dose after an initial titration period.
3. A. If a patient's response to a weight loss medication is deemed effective (weight loss greater than or equal to 5% of body weight or BMI) and safe, it is recommended that the medication be continued. [7]
4. This list includes the most prevalent comorbidities in obesity based on clinical trials and current literature. [7]

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Revision History

• 2025-01-22: Update Program
• 2024-12-20: New Program

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