Imcivree — United Healthcare

Initial criteria

• Diagnosis of obesity is due to POMC, PCSK1, or LEPR gene deficiency confirmed with genetic testing interpreted as pathogenic, likely pathogenic, or of uncertain significance OR Diagnosis of Bardet-Biedl syndrome
• AND Adult patient with BMI ≥ 30 kg/m2 OR Pediatric patient with weight >95th percentile for age on growth chart assessment
• AND Patient is currently enrolled in or has history of a weight loss management program

Reauthorization criteria

• If on therapy for less than 12 months, documentation of a positive clinical response to Imcivree therapy defined as weight loss ≥5% of baseline weight OR If on therapy for ≥12 months, documentation of a positive clinical response to Imcivree therapy defined as ≥10% weight loss from baseline

Approval duration

Initial 6 months; Reauth 12 months.