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Table 81: Anti-Obesity Agents


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Drug Category: Anti-Obesity Agents

Medication Class/Individual Agents: Anti-Obesity Agents

I. Prior-Authorization Requirements

 Anti-Obesity Agents

Clinical Notes

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

benzphetamine PA  
diethylpropion PA  
diethylpropion extended-release PA  
liraglutide-Saxenda Saxenda PA  
orlistat Xenical PA   BP, A90
phendimetrazine PA  
phendimetrazine extended-release PA  
phentermine 15 mg, 30 mg capsule PA   - < 12 years
phentermine 37.5 mg capsule, tablet Adipex-P PA   - < 12 years #
phentermine 8 mg tablet Lomaira PA   - < 12 years or ≥ 18 years
semaglutide injection-Wegovy Wegovy PA  
tirzepatide-Zepbound Zepbound PD PA  

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

 

Effective January 1, 2025, Wegovy and Saxenda will no longer be covered for the treatment of overweight or obesity for adults.

 

Phentermine Contraindication

The following are acceptable contraindications to phentermine:

  • Allergy to phentermine or any of the excipients
  • Arrhythmia
  • Bipolar disorder with mania
  • Concomitant use of stimulants
  • Congestive heart failure
  • Coronary artery disease
  • Glaucoma
  • History of psychosis
  • History of stroke
  • Hyperthyroidism
  • Substance use disorder (SUD)
  • Uncontrolled anxiety despite pharmacotherapy
  • Uncontrolled hypertension defined as average blood pressure of ≥ 140/90 mm Hg despite pharmacotherapy
 
Table Footnotes
# This designates a brand-name drug with FDA “A”-rated generic equivalents. PA is required for the brand, unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an FDA “A”-rated generic equivalent.
 
BP Brand Preferred over generic equivalents. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing the non-preferred drug generic equivalent.
 
PD Preferred Drug. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class.
 
A90 Allowable 90-day supply. Dispensing in up to a 90-day supply is allowed. May not include all strengths or formulations. Quantity limits and other restrictions may apply.
 

II. Therapeutic Uses

FDA-approved, for example:

  • Obesity
  • Overweight
  • Note: The above list may not include all FDA-approved indications.

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III.  Evaluation Criteria for Approval

  • Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.
  • All PA requests must include clinical diagnosis, drug name, dose, and frequency. 
  • Dispensing in a 90-day supply of medication may be mandated or allowable for agents in this therapeutic class (designated by M90 or A90, respectively, in the Drug Notes section above). Applicable quantity limits are described below as units per day, per month, per 28 days, or as clinically appropriate, and may be extrapolated for fills of longer day supply.
  • A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
  • For recertification requests, approval may require submission of additional documentation including, but not limited to, documentation of: some or all criteria for the original approval; response to therapy; clinical rationale for continuation of use; status of member’s condition; appropriate diagnosis; appropriate age; appropriate dose, frequency, and duration of use for requested medication; complete treatment plan; current laboratory values; and member’s current weight.
  • Additional criteria may apply depending upon diagnosis and/or requested medication (see below). Other factors, including rebate and FDA-approval status, may change independently of scheduled MassHealth updates, which may result in additional restrictions.

 

 benzphetamine, diethylpropion, diethylpropion ER, phendimetrazine ER, phendimetrazine

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 17 years of age; and
    • member weight (dated within the 90 days prior to treatment initiation); and
    • member has been counseled to continue reduced-calorie diet and increased physical activity; and
    • one of the following:
      • for diethylpropion ER or phendimetrazine ER, requested quantity is ≤ one unit/day; or
      • for benzphetamine, diethylpropion, or phendimetrazine, requested quantity is ≤ three units/day; and
    • one of the following:
      • inadequate response to phentermine with or without topiramate defined as all of the following:
        • member is adherent to phentermine (defined as ≥ 90 days out of 120 days)**; and
        • one of the following:
          • insufficient clinical response defined as < 5% reduction in body weight from baseline despite initial trial of ≥ three months of treatment with the maximally tolerated dose of phentermine; or
          • plateaued clinical response defined as no weight loss for at least ≥ three months of treatment with the maximally tolerated dose of phentermine; and
        • member’s current BMI is ≥27 kg/m2 (dated within the 90 days prior to treatment initiation of requested agent); or
      • medical records documenting adverse reaction to phentermine that is allergic in nature or cannot be expected or managed as part of weight loss therapy; or
      • medical records documenting contraindication to phentermine; and
    • one of the following:
      • member BMI is ≥ 30 kg/m2 (dated within the 90 days prior to treatment initiation); or
      • both of the following:
        • member BMI is ≥ 27 kg/m2 (dated within the 90 days prior to treatment initiation); and
        • one of the following weight-related comorbid conditions:
          • coronary heart disease or other atherosclerotic disease; or
          • dyslipidemia; or
          • hypertension; or
          • non-alcoholic steatohepatitis (NASH); or
          • obstructive sleep apnea; or
          • polycystic ovarian syndrome; or
          • prediabetes; or
          • systemic osteoarthritis; or
          • type 2 diabetes mellitus.   

 

Lomaira, phentermine 37.5 mg capsule, tablet, and phentermine 15 mg, 30 mg capsule in members < 12 years of age 

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • appropriate dosing; and
    • member weight (dated within the 90 days prior to treatment initiation); and
    • member BMI is in the 95th percentile or greater (dated within the 90 days prior to treatment initiation); and
    • member has been counseled to continue reduced-calorie diet and increased physical activity; and
    • medical necessity to support the use of phentermine in a member < 12 years of age; and
    • one of the following:
      • for phentermine 15mg, 30mg capsule or phentermine 37.5 mg capsule or tablet, requested quantity is ≤ one unit/day; or
      • for Lomaira, requested quantity is ≤ three units/day.

 

Lomaira in members ≥ 18 years of age

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • appropriate dosing; and
    • member weight (dated within the 90 days prior to treatment initiation); and
    • member has been counseled to continue reduced-calorie diet and increased physical activity; and
    • requested quantity is ≤ three units/days; and
    • one of the following:
      • inadequate response to phentermine 15 mg, 30 mg capsule or 37.5 mg tablet or capsule with or without topiramate defined as all of the following:
        • member is adherent to phentermine (defined as ≥ 90 days out of 120 days)**; and
        • one of the following:
          • insufficient clinical response defined as < 5% reduction in body weight from baseline despite initial trial of ≥ three months of treatment with the maximally tolerated dose of phentermine; or
          • plateaued clinical response defined as no weight loss for at least ≥ three months of treatment with the maximally tolerated dose of phentermine; and
        • member’s current BMI is ≥ 27 kg/m2 (dated within the 90 days prior to treatment initiation of requested agent); or
      • medical records documenting adverse reaction to phentermine 15 mg, 30 mg capsule or 37.5 mg tablet or capsule that is allergic in nature or cannot be expected or managed as part of weight loss therapy; or
      • medical records documenting contraindication to phentermine 15 mg, 30 mg capsule or 37.5 mg tablet or capsule; and 
    • one of the following:
      • member BMI is ≥ 30 kg/m2 (dated within the 90 days prior to treatment initiation); or
      • both of the following:
        • member BMI is ≥ 27 kg/m2 (dated within the 90 days prior to treatment initiation); and
        • one of the following weight-related comorbid conditions:
          • coronary heart disease or other atherosclerotic disease; or
          • dyslipidemia; or
          • hypertension; or
          • non-alcoholic steatohepatitis (NASH); or
          • obstructive sleep apnea; or
          • polycystic ovarian syndrome; or
          • prediabetes; or
          • systemic osteoarthritis; or
          • type 2 diabetes mellitus.

 

orlistat

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 12 years of age; and
    • appropriate dosing; and
    • member weight (dated within the 90 days prior to treatment initiation); and
    • member has been counseled to continue reduced-calorie diet and increased physical activity; and
    • requested quantity is ≤ three units/day; and
    • one of the following:
      • member BMI is ≥ 30 kg/m2 (dated within the 90 days prior to treatment initiation); or
      • both of the following: 
        • member is ≥ 12 years and < 17 years of age; and
        • member BMI is in the 95th percentile or greater (dated within the 90 days prior to treatment initiation); or
      • both of the following:
        • member BMI is ≥ 27 kg/m2 (dated within the 90 days prior to treatment initiation); and
        • one of the following weight-related comorbid conditions:
          • coronary heart disease or other atherosclerotic disease; or
          • dyslipidemia; or
          • hypertension; or
          • non-alcoholic steatohepatitis (NASH); or
          • obstructive sleep apnea; or
          • polycystic ovarian syndrome; or
          • prediabetes; or
          • systemic osteoarthritis; or
          • type 2 diabetes mellitus.
  • For recertification, documentation of the following is required:
    • member weight (dated within the last 90 days); and
    • one of the following:
      • weight loss of ≥ 5% from baseline body weight; or
      • both of the following:
        • improvement in secondary measures; and
        • attestation that the improvement in secondary measure is believed to be related to anti-obesity therapy despite lack of reduction in body weight.

 

Saxenda

  • Documentation of the following is required for reduction of excess body weight and long-term maintenance of weight reduction in  pediatric members with obesity or overweight:
    • appropriate diagnosis; and
    • member is ≥ 12 years and < 18 of age; and
    • appropriate dosing; and
    • member weight (dated within the 90 days prior to treatment initiation); and
    • member BMI is in the 95th percentile or greater (dated within the 90 days prior to treatment initiation); and
    • member has been counseled to continue reduced-calorie diet and increased physical activity; and
    • requested agent will not be used in combination with another GLP-1 receptor agonist; and
    • requested quantity is ≤ five pens/30 days; and
    • one of the following*:
      • inadequate response to phentermine with or without topiramate defined as all of the following: 
        • member is adherent to phentermine (defined as ≥ 90 days out of 120 days)**; and
        • one of the following:
          • insufficient clinical response defined as < 5% reduction in body weight from baseline despite initial trial of ≥ three months of treatment with the maximally tolerated dose of phentermine; or
          • plateaued clinical response defined as no weight loss for at least ≥ three months of treatment with the maximally tolerated dose of phentermine; and
        • member’s current BMI is ≥ 27 kg/m2 (dated within the 90 days prior to treatment initiation of requested agent); or
      • medical records documenting adverse reaction to phentermine that is allergic in nature or cannot be expected or managed as part of weight loss therapy; or
      • medical records documenting contraindication to phentermine.
  • For recertification in pediatric members, documentation of the following is required:
    • member weight (dated within the last 90 days); and
    • member is < 18 years of age; and
    • one of the following:
      • weight loss of ≥ 5% from baseline body weight; or
      • both of the following:
        • improvement in secondary measures; and
        • attestation that the improvement in secondary measure is believed to be related to anti-obesity therapy despite lack of reduction in body weight clinical.

 

Wegovy

  • Documentation of the following is required for reduction of excess body weight and long-term maintenance of weight reduction in  pediatric members with obesity or overweight:
    • appropriate diagnosis; and
    • member is ≥ 12 years and < 18 of age; and
    • appropriate dosing; and
    • member weight (dated within the 90 days prior to treatment initiation); and
    • member BMI is in the 95th percentile or greater (dated within the 90 days prior to treatment initiation); and
    • member has been counseled to continue reduced-calorie diet and increased physical activity; and
    • requested agent will not be used in combination with another GLP-1 receptor agonist; and
    • requested quantity is ≤ four pens/28 days; and
    • one of the following*:
      • inadequate response to phentermine with or without topiramate defined as all of the following: 
        • member is adherent to phentermine (defined as ≥ 90 days out of 120 days)**; and
        • one of the following:
          • insufficient clinical response defined as < 5% reduction in body weight from baseline despite initial trial of ≥ three months of treatment with the maximally tolerated dose of phentermine; or
          • plateaued clinical response defined as no weight loss for at least ≥ three months of treatment with the maximally tolerated dose of phentermine; and
        • member’s current BMI is ≥ 27 kg/m2 (dated within the 90 days prior to treatment initiation of requested agent); or
      • medical records documenting adverse reaction to phentermine that is allergic in nature or cannot be expected or managed as part of weight loss therapy; or
      • medical records documenting contraindication to phentermine.
  • For recertification in pediatric members, documentation of the following is required:
    • member weight (dated within the last 90 days); and
    • member is < 18 years of age; and
    • one of the following:
      • weight loss of ≥ 5% from baseline body weight; or
      • both of the following:
        • improvement in secondary measures; and
        • attestation that the improvement in secondary measure is believed to be related to anti-obesity therapy despite lack of reduction in body weight.

 

  • Documentation of the following is required for risk reduction of major adverse cardiovascular events in members with established cardiovascular disease and obesity or overweight:
    • appropriate diagnosis; and
    • member is  ≥ 18 years of age; and
    • appropriate dosing; and
    • member weight (dated within the 90 days prior to treatment initiation); and
    • member BMI is ≥ 27 kg/m2 (dated within the 90 days prior to treatment initiation); and
    • medical records documenting a diagnosis of cardiovascular disease defined as at least one of the following:
      • history of myocardial infarction (MI); or
      • history of stroke (ischemic or hemorrhagic stroke); or
      • symptomatic peripheral arterial disease (e.g., intermittent claudication with ankle–brachial index <0.85, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease); and
    • attestation that the member does not have any of the following:
      • type 1 diabetes mellitus; or
      • type 2 diabetes mellitus; or
      • New York Heart Association class IV heart failure; and
    • member has been counseled to continue reduced-calorie diet and increased physical activity; and
    • requested agent will not be used in combination with another GLP-1 receptor agonist; and
    • requested quantity is ≤ four pens/28 days.
  • For recertification in members ≥ 18 years of age, documentation of the following is required:
    • member weight (dated within the last 90 days); and
    • member requires Wegovy for cardiovascular protection and the benefit of cardiovascular protection outweighs the risk associated with the use of GLP-1 agents; and
    • medical records documenting one of the following:
      • history of myocardial infarction (MI); or
      • history of stroke (ischemic or hemorrhagic stroke); or
      • symptomatic peripheral arterial disease (e.g., intermittent claudication with ankle–brachial index <0.85, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease).

 

Zepbound

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • appropriate dosing; and
    • member weight (dated within the 90 days prior to treatment initiation); and
    • member has been counseled to continue reduced-calorie diet and increased physical activity; and
    • requested quantity is ≤ four pens/28 days; and
    • requested agent will not be used in combination with another GLP-1 receptor agonist; and
    • one of the following*:
      • inadequate response to phentermine with or without topiramate defined as all of the following:
        • member is adherent to phentermine (defined as ≥ 90 out of the last 120 days)**; and
        • one of the following:
          • insufficient clinical response defined as < 5% reduction in body weight from baseline despite initial trial of ≥ three months of treatment with the maximally tolerated dose of phentermine; or
          • plateaued clinical response defined as no weight loss for at least ≥ three months of treatment with the maximally tolerated dose of phentermine; and
        • member’s current BMI is ≥ 27 kg/m2 (dated within the 90 days prior to treatment initiation of requested agent); or
      • medical records documenting adverse reaction to phentermine that is allergic in nature or cannot be expected or managed as part of weight loss therapy; or
      • medical records documenting contraindication to phentermine; and
    • one of the following:
      • member BMI is ≥ 30 kg/m2 (dated within the 90 days prior to treatment initiation); and
      • both of the following:
        • member BMI is ≥ 27 kg/m2 (dated within the 90 days prior to treatment initiation); and
        • one of the following weight-related comorbid conditions:
          • coronary heart disease or other atherosclerotic disease; or
          • dyslipidemia; or
          • hypertension; or
          • non-alcoholic steatohepatitis (NASH); or
          • obstructive sleep apnea; or
          • polycystic ovarian syndrome; or
          • prediabetes; or
          • systemic osteoarthritis; or
          • type 2 diabetes mellitus.
  • For recertification, documentation of the following is required:
    • member weight (dated within the last 90 days); and
    • one of the following:
      • weight loss of ≥ 5% from baseline body weight; or
      • both of the following:
        • improvement in secondary measures; and
        • attestation that the improvement in secondary measure is believed to be related to anti-obesity therapy despite lack of reduction in body weight.

 

*Please note, members who have paid MassHealth pharmacy claims for a GLP-1 agonist within the last 90 days may bypass the phentermine trial. For all other members, documentation of clinical rationale why the member is not new to GLP-1 therapy is required to bypass the phentermine trial. 

**Requests will be evaluated taking into account MassHealth pharmacy claims history or additional documentation addressing adherence to these agents.


Original Effective Date: 01/2024

Last Revised Date: 01/2025


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Last updated 02/10/25

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