Saxenda (liraglutide injection) — CareFirst (Caremark)

Initial criteria

• Drug will be used with a reduced-calorie diet AND increased physical activity for chronic weight management
• Patient has participated in a comprehensive weight management program that includes behavioral modification, reduced-calorie diet, AND increased physical activity with continuing follow-up for ≥ 6 months prior to use
• If patient age ≥ 18 years: baseline BMI ≥ 30 kg/m² OR baseline BMI ≥ 27 kg/m² with at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia)
• If patient age 12–17 years: baseline body weight > 60 kg AND baseline BMI corresponding to ≥ 30 kg/m² for adults (Cole Criteria)

Reauthorization criteria

• Drug will be used with a reduced-calorie diet AND increased physical activity for chronic weight management
• If patient age ≥ 18 years: completed ≥ 16 weeks of therapy with requested drug AND lost ≥ 4% of baseline body weight OR maintained initial 4% weight loss
• If patient age 12–17 years: completed ≥ 12 weeks of therapy on maintenance dose AND had ≥ 1% reduction in BMI from baseline OR maintained initial 1% BMI reduction

Approval duration

Adults: initial 4 months, continuation 12 months; Pediatrics: initial 5 months, continuation 12 months