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Anti-Obesity Medications

DrugAnti-Obesity Medications

December 2021

Covered drugs with prior authorization:

  • Benzphetamine
  • Contrave
  • Diethylpropion and diethylpropion ER
  • Lomaira
  • Phendimetrazine and phendimetrazine ER
  • Phentermine capsules (Apidex-P and generics):  15mg, 30mg, 37.5mg
  • Phentermine tablets (Apidex-P and generics):  37.5mg
  • Qsymia
  • 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
  • Documented failure of at least a three-month trial on a low-calorie diet AND
  • A 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 OR
    • Greater than or equal to 27 kg/m2 with at least one very high-risk factor OR
  • At least two other risk factors (see Table 1) OR
  • Waist circumference must be greater than 102 cm for men and greater than 88 cm for women with at least one very high-risk factor AND
  • No contraindications (disease state or current therapy) should exist unless the prescriber documents that benefits outweigh risks (see Table 2) AND
  • No concurrent use of any other weight loss drug(s) AND
  • If the request is for Wegovy, patient must have failed a 3-month adherent trial of Saxenda AND
  • Patient’s weight at baseline (in pounds) must be submitted at time of request
  • Initial approval is for 3 months

Table 1:  Risk Factors

Risk Disease
Very high risk
  • Type 2 diabetes
  • Established coronary heart disease
  • Other atherosclerotic disease
  • Sleep apnea
Other risk factors
  • Hypertension
  • Dyslipidemia
  • Impaired fasting glucose concentration
  • Cigarette smoking
  • Family history of premature heart disease
  • Age (men older than 45 years, women older than 55 years or postmenopausal)
  • Gynecologic abnormalities
  • Osteoarthritis
  • Gallstones
  • Stress incontinence


Table 2:  Contraindications, Precautions, and Drug Interactions

Drug Contraindications Precautions Drug Interactions
Benzphetamine
  • History of glaucoma
  • History of hypertension (moderate to severe)
  • History of hyperthyroidism 
  • History of cardiovascular disease
  • Co-administration of other stimulants
  • History of drug abuse
  • History of anxiety disorders
  • History of diabetes mellitus
  • History of hypertension (mild)
Monoamine oxidase inhibitors (MAOI): contraindicated
Contrave
  • Uncontrolled hypertension
  • Seizure disorders 
  • Anorexia nervosa or bulimia
  • Undergoing abrupt discontinuation of alcohol, benzodiazepines, barbiturates, or antiepileptic drugs
  • Concurrent use of other bupropion-containing products if the total daily dose of all bupropion-containing products is above the FDA maximum recommended dose
  • Chronic opioid use
  • During or within 14 days of taking MAOI
  • Suicidal thoughts and ideation
  • MAOI
  • Opioid analgesics
Diethylpropion and diethylpropion ER
  • History of glaucoma
  • History of hypertension (moderate to severe)
  • History of hyperthyroidism 
  • History of cardiovascular disease
  • Co-administration of other stimulants
  • History of drug abuse
  • History of anxiety disorders
  • History of diabetes mellitus
  • History of hypertension (mild)
  • Monoamine oxidase inhibitors (MAOI): contraindicated
Lomaira
  • History of glaucoma
  • History of hypertension (moderate to severe)
  • History of hyperthyroidism 
  • History of cardiovascular disease
  • Co-administration of other stimulants
  • History of drug abuse
  • History of anxiety disorders
  • History of diabetes mellitus
  • History of hypertension (mild)
  • Monoamine oxidase inhibitors (MAOI): contraindicated
Phendimetrazine and phendimetrazine ER
  • History of glaucoma
  • History of hypertension (moderate to severe)
  • History of hyperthyroidism
  • History of cardiovascular disease
  • Co-administration of other stimulants
  • History of drug abuse
  • History of anxiety disorders
  • History of diabetes mellitus
  • History of hypertension (mild)
  • Monoamine oxidase inhibitors (MAOI): contraindicated
Qsymia
  • Pregnancy
  • Glaucoma
  • Hyperthyroidism
  • During or within 14 days of taking MAOI
  • Increase in heart rate
  • Suicidal behavior and ideation
  • Acute myopia and secondary angle closure glaucoma
  • Oral contraceptive
  • Non-potassium sparing diuretic
  • CNS depressants including alcohol
Saxenda
  • Pregnancy
  • Personal or family history of medullary thyroid carcinoma or Multiple Endocrine
  • Neoplasia syndrome type 2 
  • Co-administration of insulin
  • Co-administration of GLP-1 receptor agonist
  • Suicidal behavior and
  • ideation
  • Acute pancreatitis
  • Acute gallbladder disease
  • Renal impairment
Wegovy
  • Pregnancy
  • Personal or family history of medullary thyroid carcinoma or Multiple Endocrine
  • Neoplasia syndrome type 2
  • Co-administration of insulin
  • Co-administration of GLP-1 receptor agonist
  • Suicidal behavior and 
  • ideation
  • Acute pancreatitis
  • Acute gallbladder disease
  • Renal impairment
Xenical
  • Chronic malabsorption syndrome
  • Cholestasis
  • History of hyperoxaluria or caoxalate nephrolithiasis 
  • Patients with deficiency of any fat-soluble vitamins

Renewal criteria for covered drugs with prior authorization:

  • Ongoing prescriber documentation of adherence to a low-calorie diet AND
  • A regimen of increased physical activity (unless medically contraindicated by co-morbidity) during anti-obesity therapy AND
  • No contraindications (disease state or current therapy) should exist, unless prescriber documents that benefits outweigh risks (see Table 2) AND
  • Patient must have lost at least 5% during the initial approval period AND
  • Renewal approval is for 6 months AND
  • Patient’s most recent weight (in pounds) must be submitted with each prior authorization request AND
  • After 6 months of therapy, a 6-month approval may be granted if a 5% weight reduction has been achieved AND
  • After one year of therapy, additional 6-month approvals may be granted if a 5% weight reduction has been achieved AND the patient continues to maintain weight loss AND
  • After lapses of therapy, additional trials may be approved if criteria requirements are met AND
  • Xenical may not be approved for therapy beyond four years

Quantity limits

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

Questions?

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

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