Saxenda — 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 ≥ 1% from baseline; AND
• The medication will be used concomitantly with behavioral modification and a reduced-calorie diet

Approval duration

initial 4 months, reauth 1 year