Weight Management Agents

May 2026

Please refer to the Preferred Drug List for the preferred and non-preferred status of drugs.

  • All drugs require prior authorization
  • For drugs with an FDA-approved indication for weight loss that are being requested for weight loss purposes, coverage may be provided if members meet the prior authorization (PA) criteria for “Anti-Obesity Medications”
  • For agents with other FDA-approved indications that are not being requested for weight loss purposes, coverage may be provided if members meet PA criteria below

Initial and renewal approval criteria (up to 12 months)

Reduce risk of major adverse cardiovascular events (MACE)

  • The requested drug is FDA approved for MACE; AND
  • Diagnosis of obesity or overweight; AND
  • Patient must meet the age limit indicated in the FDA-approved label of the requested drug
    AND
    (one of the following)
    • 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
  • No concurrent use of any other GLP-1 receptor agonist; AND
  • Diagnosis of established cardiovascular (CV) disease; AND
  • Documentation of management of CV risk factors; AND
  • Requested agent is prescribed by or in consultation with a cardiologist

Treat noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH)

  • The requested drug is FDA approved for MASH; AND
  • Patient must meet the age limit indicated in the FDA-approved label of the requested drug
    AND
    (one of the following)
    • 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
  • No contraindications (disease state or current therapy) should exist unless the prescriber documents that benefits outweigh risks; AND
  • No concurrent use of any other GLP-1 receptor agonist; AND
  • Diagnosis of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH); AND
  • Moderate to advanced liver fibrosis (consistent with stages F2 to F3 fibrosis); AND
  • Requested agent is prescribed by on in consultation with a gastroenterologist or hepatologist

Treat moderate to severe obstructive sleep apnea (OSA)

  • The requested drug is FDA approved for OSA; AND
  • Diagnosis of obesity; AND
  • Patient must meet the age limit indicated in the FDA-approved label of the requested drug;
    AND
    (one of the following)
    • 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
  • No concurrent use of any other GLP-1 receptor agonist; AND
  • Diagnosis of moderate to severe obstructive sleep apnea (OSA); AND
  • Requested agent is prescribed by a sleep specialist, pulmonologist, ENT specialist, or cardiologist

Quantity limits

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

Questions?

Provider Call Center: (844) 575-7887