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
Chronic Weight Management Indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in: 1) Adult and pediatric patients aged 12 years and older with obesity 2) Adults who are overweight in the presence of at least one weight-related comorbid condition. Limitations of Use: The effect of Qsymia on cardiovascular morbidity and mortality has not been established. The safety and effectiveness of Qsymia in combination with other products intended for weight loss, including prescription and over-the-counter drugs, and herbal preparations, have not been established.
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, 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)
For diagnosis of Morbid Obesity
- Treatment is being requested for morbid obesity AND
- All of the following:
- Patient is greater than 16 years of age
- Submission of medical records (e.g. Chart Notes) confirming baseline BMI greater than or equal to 40 kg/m2 prior to initiating therapy
- Not being co-administered with other weight loss agents indicated for short-term weight reduction or chronic weight management (e.g., Qsymia, Contrave)
- 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)
For diagnosis of Morbid Obesity
- Patient's baseline and current weight and BMI is provided AND
- Patient’s submission of medical records (e.g. Chart Notes) confirming BMI at baseline was greater than or equal to 40 kg/m2 AND
- Submission of medical records (e.g., chart notes) confirming weight loss of greater than or equal to 5% of baseline body weight^ 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
Prior Authorization (Initial Authorization)
Length of Approval: 6 Month(s)
For diagnosis of Short-term Weight Reduction
- Treatment is being requested for appetite suppression or weight loss AND
- One of following:
- All 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
- Not being co-administered with other weight loss agents indicated for short-term weight reduction or chronic weight management
- 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)
For diagnosis of Short-term Weight Reduction
- Weight loss of greater than or equal to 5% of baseline body weight [C]
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)
For diagnosis of Morbid Obesity
- Treatment is being requested for morbid obesity AND
- All of the following:
- Patient is 18 years of age or older
- Submission of medical records (e.g. Chart Notes) confirming baseline BMI greater than or equal to 40 kg/m2 prior to initiating therapy
- Not being co-administered with other weight loss agents indicated for short-term weight reduction or chronic weight management (e.g., Phentermine)
- 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)
For diagnosis of Morbid Obesity
- Patient’s baseline and current weight and BMI is provided AND
- Patient’s submission of medical records (e.g. Chart Notes) confirming BMI at baseline was greater than or equal to 40 kg/m2 AND
- Submission of medical records (e.g., chart notes) confirming weight loss of greater than or equal to 5% of baseline body weight^ 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*
*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
- 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)
- 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)
- 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
Brand Qsymia*, generic phentermine-topiramate, 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)
- Treatment is being requested for appetite suppression or weight loss. AND
- One of the following:
- All 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
- Not being co-administered with other weight loss agents indicated for short-term weight reduction or chronic weight management (e.g., Phentermine)
- 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)
- 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
- For Qsymia 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
Brand Qsymia, generic phentermine-topiramate, 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]
P & T Revisions
2025-09-19, 2025-03-17, 2025-03-03, 2025-01-22, 2024-12-20
References
- Adipex-P Prescribing Information. Teva Pharmaceuticals USA, Inc. Parsippany, NJ . September 2020.
- Xenical Prescribing Information. CHEPLAPHARM Arzneimittel GmbH. Greifswald, Germany. November 2020.
- Qsymia Prescribing Information. Vivus, Inc. Campbell, CA. June 2022.
- Lomaira Prescribing Information. KVK-Tech, Inc. Newtown, PA. December 2018.
- Contrave Prescribing Information. Nalpropion Pharmaceuticals, Inc. La Jolla, CA. October 2020.
- Orlistat Prescribing Information. H2-Pharma, LLC. Montgomery, AL. June 2022
- 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.
- 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.
End Notes
- 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]
- A patient receiving Contrave is recommended to be evaluated by week 12 at the maintenance dose after an initial titration period.
- 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]
- This list includes the most prevalent comorbidities in obesity based on clinical trials and current literature. [7]
Revision History
- 2025-09-19: Updating criteria to only allow a pathway to coverage for BMI greater than or equal to 40 for morbid obesity. Also added generic phentermine-topiramate prior authorization criteria.
- 2025-03-17: Update Program
- 2025-03-03: Updated guideline
- 2025-01-22: Update Program
- 2024-12-20: New Program
HEALTHY LIVING