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Saxenda — Cigna

Weight loss in a pediatric patient with obesity

Preferred products

  • Contrave
  • Qsymia (phentermine/topiramate extended-release capsules, generic)

Initial criteria

  • Patient age ≥ 12 years (≥ 18 years for Zepbound)
  • Patient with ICD-10 codes for pediatric BMI ≥ 95th percentile for age (Z68.54, Z68.55, Z68.56) may qualify for automation approval of Wegovy or liraglutide (Saxenda, generic)

Reauthorization criteria

  • Patient age ≥ 12 years (≥ 18 years for Zepbound)
  • Patient established on Contrave, Qsymia (phentermine/topiramate extended-release capsules, generic), liraglutide (Saxenda, generic), Wegovy, and/or Zepbound collectively for at least 90 days, with prescription claims history showing at least a 90-day supply dispensed within the past 130 days, is allowed continuation of therapy