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GLP-1 Weight Loss Authorization Requests

Date: 09/06/24

There are several GLP-1 agents that can be used for weight loss that require a PA. Please see the information below to ensure that all the required information is submitted with the PA request.

  • Liraglutide (Saxenda®)
  • Semaglutide (Wegovy™)
  • Tirzepatide (Zepbound™)

Benzphetamine, Diethylpropion, Phendimetrazine, Naltrexone/Bupropion, Orlistat, Phentermine, and Phentermine/Topiramate are covered weight loss agents, but do not require a PA.

For initial requests:

  • The dose must be approved for weight management and cannot exceed the following dosing limits:

Medication

Age

Dosing Limits

Liraglutide (Saxenda®) 

≥12 years 

3 mg SC once daily 

Semaglutide (Wegovy™) 

≥12 years 

2.4 mg SC once weekly 

Tirzepatide (Zepbound™)

≥18 years 

15 mg SC once weekly

  • Tirzepatide (Zepbound™) is the preferred GLP-1 agent for weight loss. The member must try and fail Tirzepatide (Zepbound™) prior to using other GLP-1 agents unless the patient is less than 18 years old or the member has an indication for cardiovascular disease prevention.

  • Providers must submit the member’s baseline and current weight. If a baseline weight and BMI is not submitted, the PA will be denied.
    • For Tirzepatide (Zepbound™), the member must have a baseline BMI ≥30 kg/m2 OR BMI ≥27 kg/m2 AND has at least one weight-related comorbidity.
    • For Liraglutide (Saxenda®) or Semaglutide (Wegovy™), the member must have a baseline BMI ≥40 kg/m2. For adolescent (age 12-17) patients, the member must have a baseline BMI ≥40kg/m2 or ≥140% of the 95th percentile by age and sex.
    • For Semaglutide (Wegovy™) the member must have a baseline BMI ≥27kg/m2 AND has established cardiovascular disease (CVD) and NOT have a history of type I nor type II diabetes.
      • Established CVD means history of myocardial infarction, stroke, or symptomatic peripheral arterial disease.
  • If the member has a diagnosis of type 2 diabetes, they must use the GLP-1 formulation indicated for diabetes. Prior Authorization is still required.
    • Ozempic® (semaglutide)
    • Victoza® (liraglutide)
    • Mounjaro® (tirzepatide)

  • The member must have trialed adjunct lifestyle interventions (e.g., diet modification, physical activity) for at least 3 months. This requirement does not apply to Tirzepatide (Zepbound™).

  • If the member previously failed a GLP-1 agent, a minimum one-year period is required. See the full PA criteria for more information on exceptions.

For renewals:

  • The member must continue to include comprehensive adjunct lifestyle interventions.

  • The member must meet the weight or BMI loss criteria listed in the table below. Providers must submit the member’s most recent weight and BMI. If a most recent weight and BMI is not submitted, the PA will be denied.

 

% Loss from Baseline (Initial 8 Weeks) 

% Loss from Baseline (Subsequent Renewals) 

% Loss from Baseline (≥52 weeks)

Liraglutide (Saxenda®) 

Adults

3%

7%

10%

Adolescents

3%*

5%*

10%**

Semaglutide (Wegovy™) 

Adults

5%

10%

15%

Adolescents

4%*

8%*

15%**

Tirzepatide (Zepbound™)

Adults

5%

10%

10%

* % loss means % BMI loss.

** % loss means % BMI loss or % of 95th percentile loss.

KDHE Resource Links

Anti-Obesity Medication Prior Authorization Form

Anti-Obesity Medication Criteria

KS Preferred Drug List