liraglutide (Saxenda, generic) — Cigna

Initial criteria

• Patient is age ≥ 12 years and < 18 years; AND
• Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months; AND
• At baseline, patient had a BMI ≥ 95th percentile for age and sex; AND
• The medication will be used concomitantly with behavioral modification and a reduced-calorie diet.

Reauthorization criteria

• Patient is age ≥ 12 years and < 18 years; AND
• At baseline, patient had a BMI ≥ 95th percentile for age and sex; AND
• Patient has had a reduction in BMI of ≥ 1% from baseline; AND
• The medication will be used concomitantly with behavioral modification and a reduced-calorie diet.

Approval duration

initial 4 months; continuation 1 year