Anti-Obesity Agents – NC Standard

Restriction applies to brand and generic products 

• Adipex-P (phentermine) 
• Benzphetamine 
• Contrave (bupropion/naltrexone extended release) 
• Diethylpropion 
• Lomaira (phentermine)
• Phendimetrazine 
• Qsymia (phentermine/topiramate extended release) 
• Saxenda (liraglutide)
• Wegovy (semaglutide)
• Zepbound (tirzepatide)

• Adipex-P , Benzphetamine, Diethylpropion, Lomaira, Phendimetrazine
  • As an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of 30 kg/m² or greater (obesity) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (eg, hypertension, type 2 diabetes mellitus, or dyslipidemia).
• Contrave, Qsymia 
  • As an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of 30 kg/m² or greater (obesity) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (eg, hypertension, type 2 diabetes mellitus, or dyslipidemia) and pediatric patients ≥ 12 years of age with an initial BMI in the ≥95^th percentile standardized for age and sex.
• Saxenda, Wegovy, & Zepbound: 
  • As an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of 30 kg/m² or greater (obesity) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, or dyslipidemia). 
• Saxenda:
  • As an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in pediatric patients aged 12 years and older with body weight above 60 kg and an initial BMI corresponding to ≥30 kg/m² for adults (obese) by international cut-offs. 
• Wegovy:
  • As an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in pediatric patients aged 12 years and older with an initial BMI at the 95th percentile or greater for age and sex (obesity).
  • As an adjunct to a reduced-calorie diet and increased physical activity to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in adults with established cardiovascular disease and either an initial BMI of ≥30 kg/m² (obesity), or ≥27 kg/m² (overweight)
• Zepbound:
  • To treat moderate to severe obstructive sleep apnea (OSA) in adults with obesity

1. The patient is 18 years of age or older; AND
   1. The patient has ONE of the following: 
      1. A diagnosis of obesity and a BMI ≥ 30 kg/m2 ; OR
      2. A diagnosis of obesity and a BMI ≥ 25 kg/m2 and the patient is of South Asian, Southeast Asian, or East Asian descent; OR
      3. The patient has a documented BMI ≥ 27 kg/m2 with at least one weight-related comorbidity/risk factor/complication (e.g. cardiovascular disease, coronary artery disease, hypertension, sleep apnea, knee-osteoarthritis, type II diabetes, dyslipidemia, polycystic ovarian syndrome, non-alcoholic steatohepatitis/non-alcoholic fatty liver disease, and asthma); OR
   2. The request is for Wegovy (semaglutide); AND
      1. The patient is using the medication to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in adults with established cardiovascular disease; AND
      2. The patient has a history of ONE of the following: 
         1. Myocardial infarction; OR 
         2. Stroke; OR 
         3. Peripheral artery disease as defined by intermittent claudication with ankle-brachial index less than 0.85 at rest, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease; AND 
      3. The patient has a BMI ≥ 27 kg/m2 ; AND 
      4. The patient will use optimized pharmacotherapy for established cardiovascular disease in combination with Wegovy; OR
   3. The request is for Zepbound (tirzepatide); AND
      1. The patient has a BMI ≥ 30 kg/m²; AND
      2. The patient has a diagnosis of moderate to severe obstructive sleep apnea; AND
         1. The patient has had a polysomnography (PSG) or home sleep apnea test; AND
         2. The patient has an apnea hypopnea index (AHI) ≥ 15 at baseline; OR
2. The patient is 12 – 17 years of age; AND
   1. The request is for Saxenda (liraglutide); AND
      1. The patient has a body weight of > 60 kg; AND
      2. The patient has a diagnosis of obesity and a BMI corresponding to ≥30 kg/m2 for adults by international cut-offs; OR
   2. The request is for Wegovy (semaglutide); AND
      1. The patient has a diagnosis of obesity and a BMI > 95th percentile for age and sex; AND 
3. The requested medication will NOT be used concurrently with another GLP-1 receptor agonist medication; AND
4. The requested medication will NOT be used concurrently with another weight loss medication; AND 
5. The provider has addressed the requirement for lifestyle modifications (calorie restrictions and increased activity) while taking the requested medication; AND
6. The patient was unable to achieve acceptable weight loss through lifestyle modifications (defined as a 1lb per week weight loss through calorie restriction, increased activity, and behavioral modifications in a 6 month period); OR 
   1. The patient has a weight-related comorbidity/risk factor/complication (e.g. cardiovascular disease, coronary artery disease, hypertension, sleep apnea, knee-osteoarthritis, type II diabetes, dyslipidemia, polycystic ovarian syndrome, non-alcoholic steatohepatitis/non-alcoholic fatty liver disease, and asthma) that warrants medication interventions immediately; AND 
7. The patient has anti-obesity medication coverage benefits; AND 
8. For formularies that exclude (non-formulary) the requested medication, Non-formulary Exception Criteria applies.

Duration of Approval: 180 days (6 months)

1. The patient was approved through Blue Cross NC initial coverage criteria; OR 
   1. The patient would have met criteria for approval at the time they started therapy; AND
2. The patient is 18 years of age or older; AND
   1. The request is for Saxenda (liraglutide); AND
      1. The patient has achieved and maintained a weight loss of ≥ 4% from baseline (prior to the initiation of requested medication); OR
   2. The request is for Wegovy (semaglutide); AND 
      1. The patient has achieved and maintained a weight loss of ≥ 5% from baseline (prior to the initiation of requested medication); OR
      2. The patient is using the medication to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in adults with established cardiovascular disease; AND
         1. The patient will use optimized pharmacotherapy for established cardiovascular disease in combination with Wegovy; AND 
         2. The patient has demonstrated a positive clinical response while using the medication; OR
   3. The request is for Zepbound (tirzepatide); AND
      1. The patient has achieved and maintained a weight loss of ≥ 5% from baseline (prior to the initiation of requested medication); OR
      2. The patient has a diagnosis of moderate to severe obstructive sleep apnea; AND
         1. The patient has demonstrated a positive clinical response while using the medication; OR
3. The patient is 12 – 17 years of age; AND
   1. The request is for Saxenda (liraglutide); AND
      1. The patient has achieved and maintained a BMI reduction of ≥ 1% from baseline (prior to the initiation of requested medication); OR
   2. The request is for Wegovy (semaglutide); AND
      1. The patient has achieved and maintained a BMI reduction of ≥ 5% from baseline (prior to the initiation of requested medication); AND
4. The patient has anti-obesity medication coverage benefits.

Duration of Approval: 365 days (1 year)

1. ONE of the following 
   1. The patient is 12 -17 years of age; AND
      1. The patient has a diagnosis of obesity and a BMI ≥ 95th percentile when standardized for age and sex; OR 
   2. The patient is 18 years of age or older; AND 
      1. The patient has one of following:
         1. A diagnosis of obesity and a BMI ≥ 30 kg/m2 ; OR 
         2. A diagnosis of obesity and a BMI ≥ 25 kg/m2 and the patient is of South Asian, Southeast Asian, or East Asian descent; OR
         3. The patient has a documented BMI ≥ 27 kg/m2 with at least one weight-related comorbidity/risk factor/complication (e.g. diabetes, dyslipidemia, coronary artery disease); AND
2. The requested medication will NOT be used concurrently with another weight loss medication; AND 
3. The provider has addressed the requirement for lifestyle modifications (calorie restrictions and increased activity) while taking the requested medication; AND
4. The patient was unable to achieve acceptable weight loss through lifestyle modifications (defined as a 1lb per week weight loss through calorie restriction, increased activity, and behavioral modifications in a 6 month period); OR
   1. The patient has a weight-related comorbidity/risk factor/complication (e.g. diabetes, dyslipidemia, coronary artery disease) that warrants medication interventions immediately; AND 
5. The patient has anti-obesity medication coverage benefits; AND
6. For formularies that exclude (non-formulary) the requested medication, Non-formulary Exception Criteria applies.

Duration of Approval: 180 days (6 months)

1. The patient was approved through Blue Cross NC initial coverage criteria; OR
   1. The patient would have met criteria for approval at the time they started therapy; AND
2. The patient has achieved and maintained a weight loss of ≥ 5% from baseline (prior to the initiation of requested medication); AND 
3. The patient has anti-obesity medication coverage benefits. 

Duration of Approval: 365 days (1 year)

1. The patient is 17 years of age or older; AND
2. The patient has one of following:
   1. A diagnosis of obesity and a BMI ≥30 kg/m2 ; OR
   2. A diagnosis of obesity and a BMI ≥ 25 kg/m2 and the patient is of South Asian, Southeast Asian, or East Asian descent; OR 
   3. The patient has a documented BMI ≥ 27 kg/m2 with at least one weight-related comorbidity/risk factor/complication (e.g. diabetes, dyslipidemia); AND
3. The requested medication will NOT be used concurrently with another weight loss medication; AND
4. The provider has addressed the requirement for lifestyle modifications (calorie restrictions and increased activity) while taking the requested medication; AND 
5. The patient was unable to achieve acceptable weight loss through lifestyle modifications (defined as a 1lb per week weight loss through calorie restriction, increased activity, and behavioral modifications in a 6 month period); OR 
   1. The patient has a weight-related comorbidity/risk factor/complication (e.g. diabetes, dyslipidemia) that warrants medication interventions immediately; AND 
6. The patient does NOT have any of the following: 
   1. History of cardiovascular disease (e.g. coronary artery disease, stroke, arrhythmias, congestive heart failure, uncontrolled hypertension)
   2. Concomitant use of a monoamine oxidase inhibitor therapy within the last 14 days (i.e., Marplan, Nardil, etc.)
   3. Concomitant use of other central nervous system stimulants (i.e., Provigil, Nuvigil, Adderall, Concerta, Vyvanse etc.)
   4. Concomitant use of other serotonergic medications (i.e., Zoloft, Prozac, Cymbalta, Pristiq etc.)
   5. Hyperthyroidism 
   6. Glaucoma
   7. Agitated states
   8. History of drug abuse
   9. Pregnancy and/or Nursing
   10. Hypersensitivity or idiosyncrasy to sympathomimetic amines; AND 
7. The patient has anti-obesity medication coverage benefits; AND
8. For formularies that exclude (non-formulary) the requested medication, Non-formulary Exception Criteria applies.

Duration of Approval: 365 days (1 year)

Quantity limitations apply to brand and associated generic products.

1. The quantity (dose) requested is for documented titration purposes at the initiation of therapy (authorization for a 90 day titration period); AND 
2. The prescribed dose cannot be achieved using a lesser quantity of a higher strength; AND 
3. The quantity (dose) requested does not exceed the maximum FDA labeled dose, when specified, or to the safest studied dose per the manufacturer’s product insert; OR 
4. If the quantity (dose) requested exceeds the maximum FDA labeled dose, when specified, or to the safest studied dose per the manufacturer’s product insert, then the prescriber must submit documentation in support of therapy with a higher dose for the intended diagnosis (submitted documentation may include medical records OR fax form which reflects medical record documentation that shows the length of time the requested dose has been used, and what other medications and doses have been tried and failed).

Duration of Approval: 365 days (1 year) 

All information referenced is from FDA package insert unless otherwise noted below.

Misra, Anoop. “Ethnic-Specific Criteria for Classification of Body Mass Index: A Perspective for Asian Indians and American Diabetes Association Position Statement.” Diabetes technology & therapeutics vol. 17,9 (2015): 667-71. doi:10.1089/dia.2015.0007

Criteria and treatment protocols are reviewed annually by the Blue Cross NC P&T Committee, regardless of change. This policy is reviewed in Q1 annually.

April 2025: Criteria change (Zepbound): Updated Zepbound initial criteria for obstructive sleep apnea in adults with obesity. Updated duration of approval for Contrave, Qsymia, Saxenda, Wegovy, and Zepbound initial criteria to 180 days. 

January 2025: Criteria change (Zepbound): Updated Zepbound initial and continuation criteria to allow coverage for obstructive sleep apnea in adults with obesity.

October 2024: Criteria change (Wegovy): Updated Wegovy’s initial and continuation criteria to allow coverage to reduce risk of major adverse events in adults with established cardiovascular disease.

July 2024: Criteria change (Wegovy, Zepbound): Updated Wegovy’s and Zepbound’s continuation coverage for adults to require a weight loss reduction of ≥ 5% from baseline. Updated QL for titration doses of Wegovy and Zepbound. Updated duration of approval for Quantity Limit Exception criteria to 365 days.

May 2024: Criteria update: Removed QL from maintenance doses of Wegovy and Zepbound

April 2024: Criteria change (Saxenda, Wegovy, Zepbound): Removed criteria point restricting concurrent use with insulin. Removed the step requirement from Zepbound.

March 2024: Criteria update: Added new FDA approved indication for Wegovy.

November 2023: Criteria update: Added new to market Zepbound to the policy.

September 2023: Criteria change (Wegovy): Updated Wegovy’s QL for the 1.7 mg strength to allow coverage for maintenance dosing.

April 2023: Criteria change: Updated Saxenda’s continuation coverage for ages 12-17 to a BMI reduction from baseline. Removed criteria point regarding previous weight loss medication trials in the last 12 months.

February 2023: Criteria change (Wegovy): Updated Wegovy to allow coverage for ages 12-17 due to expanded indication.

January 2023: Criteria change: Members required to have anti-obesity medication coverage benefits. Created one Anti-Obesity Agents policy.

July 2022: Criteria change (Contrave & Qsymia): Updated Qsymia to allow coverage for ages 12-17 due to expanded indication. Belviq removed from policy (obsolete product). Policy updated to NC Standard.

December 2021: Criteria update: Authorizations for titration purposes updated to 30 day period

July 2021: Criteria change (Saxenda & Wegovy): Combined Enhanced with Enh/NR criteria; Name changed to NC Standard (Enhanced formulary no longer required to step through Qsymia); Wegovy added to policy.

June 2021: Criteria update (Short Term Weight Loss): Annual criteria review. Removed discontinued brand products: Bontril, Didrex, Regimex. Changed duration of approval to 1 year. Removed limit of 12 weeks of therapy per 365 days.

April 2021: Criteria change (Saxenda): Applied this criterion to Essential formulary. (Essential formulary no longer required to step through Qsymia).

Dec 2020: Criteria update (Saxenda): Added expanded indication for pediatric patients ≥ 12 years of age.

April 2019: Policy originated for Net Results formulary (Saxenda)

Feb 2019: Updated criteria points regarding lifestyle modifications for language simplification

Jan 2019: Aligned medical necessity language across formularies including; BMI ranges for ancestral origin; weight loss requirement during non-pharmacological therapy.

Oct 2018: Original utilization management criteria issued.