liraglutide (Saxenda, generic) — Cigna

Initial criteria

• Patient is age ≥ 18 years; AND
• Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months; AND
• Patient meets ONE of the following (a or b):
• a) At baseline, patient had a BMI ≥ 30 kg/m2; OR
• b) Patient meets BOTH of the following [(1) and (2)]: (1) At baseline, patient had a BMI ≥ 27 kg/m2; AND (2) At baseline, patient had, or currently has, ≥ 1 of the following weight-related comorbidities: hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, cardiovascular disease, knee osteoarthritis, asthma, chronic obstructive pulmonary disease, metabolic dysfunction-associated steatotic liver disease/non-alcoholic fatty liver disease, polycystic ovarian syndrome, or coronary artery disease; AND
• The medication will be used concomitantly with behavioral modification and a reduced-calorie diet.

Reauthorization criteria

• Patient is age ≥ 18 years; AND
• Patient meets ONE of the following (a or b):
• a) At baseline, patient had a BMI ≥ 30 kg/m2; OR
• b) Patient meets BOTH of the following [(1) and (2)]: (1) At baseline, patient had a BMI ≥ 27 kg/m2; AND (2) At baseline, patient had, or currently has, ≥ 1 of the following weight-related comorbidities: hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, cardiovascular disease, knee osteoarthritis, asthma, chronic obstructive pulmonary disease, metabolic dysfunction-associated steatotic liver disease/non-alcoholic fatty liver disease, polycystic ovarian syndrome, or coronary artery disease; AND
• Patient has lost ≥ 4% of baseline body weight; AND
• The medication will be used concomitantly with behavioral modification and a reduced-calorie diet.

Approval duration

initial 4 months; continuation 1 year