Liraglutide (Saxenda)

SELF-ADMINISTRATION - INJECTION

Indications for Prior Authorization:

  • Indicated as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults

Patients must meet the following criteria for the indications above:

  • BMI > 30 kg/m2, AND

  • At least one comorbid condition confirmed by chart note documentation/prescription data:
    • Hypertension
    • Diabetes
    • Hyperlipidemia, AND
  • Patient has tried and failed one or more of the following: Belviq, Qsymia or Contrave, AND
  • Patient is not concomittantly taking Saxenda with any other other weight loss agents

The Following Conditions Do Not Meet the Criteria for Use as Established by the WHA P & T Committee:

  • All non-FDA approved indications
  • Patients who are pregnant or may become pregnant during therapy
  • Patients who have personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neopalsia syndrome type 2

Dosing:

  • Initial: 0.6 mg per day for one week.  Dose is increased at weekly intervals until a dose of 3 mg daily is reached.
  • Discontinue if weight loss >5% not achieved in 12 weeks

Approval:

  • Initial approval: 12 weeks
  • Renewal: 6 months
  • Renewal requires chart note documentation of reduction in patient weight

Last review date: June 28, 2017

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