Weight Management Drugs
PDL Reference Documents
- Wegovy (semaglutide) PA Update - Aug 01, 2024
- Nonalcoholic steatohepatitis (NASH) - Aug 01, 2024
- Semaglutide Prior Authorization Update - Jun 06, 2024
- Drugs for Weight Management - Apr 04, 2024
- New Drug Evaluation: Belviq (lorcaserin hydrochloride), Qsymia (phentermine and topiramate extended release) - Nov 29, 2012
Newsletters
- January 2025 - Off-label Uses of GLP-1 Receptor Agonists and Dual GLP-1/GIP Receptor Agonists
- October 2024 - New and Emerging Therapies for Metabolic Dysfunction-Associated Steatotic Liver Disease/Metabolic Dysfunction-Associated Steatohepatitis (MASLD/MASH) in Adults
- July 2024 - Lifestyle Modifications for Obesity: Recommendations and Benefits
- September 2023 - An Update in Weight Loss Therapies - Including FDA Approved GLP-1 Receptor Agonists
- November 2015 - Obesity and Related Sequelae: Are Medications the Answer?
- December 2012 - The Future of Newer Obesity Medications
PDL Status Values
Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the
Non-Preferred Drugs in Select PDL Classes prior authorization criteria.
New drugs will be listed as N until reviewed by the P&T Committee and are subject to the
New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.
To request a Prior Authorization, please use this form.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 10702004001 | BENZPHETAMINE HCL | benzphetamine HCl | TABLET | 50 mg | Y | PA Document | |
| 10702004003 | BENZPHETAMINE HCL | benzphetamine HCl | TABLET | 50 mg | Y | PA Document | |
| 10702004050 | BENZPHETAMINE HCL | benzphetamine HCl | TABLET | 50 mg | Y | PA Document | |
| 42806008101 | BENZPHETAMINE HCL | benzphetamine HCl | TABLET | 50 mg | Y | PA Document | |
| 42806008130 | BENZPHETAMINE HCL | benzphetamine HCl | TABLET | 50 mg | Y | PA Document | |
| 64720019403 | BENZPHETAMINE HCL | benzphetamine HCl | TABLET | 50 mg | Y | PA Document | |
| 64720019410 | BENZPHETAMINE HCL | benzphetamine HCl | TABLET | 50 mg | Y | PA Document | |
| 64720019450 | BENZPHETAMINE HCL | benzphetamine HCl | TABLET | 50 mg | Y | PA Document | |
| 00527147501 | DIETHYLPROPION HCL | diethylpropion HCl | TABLET | 25 mg | Y | PA Document | |
| 10702004401 | DIETHYLPROPION HCL | diethylpropion HCl | TABLET | 25 mg | Y | PA Document | |
| 10702004406 | DIETHYLPROPION HCL | diethylpropion HCl | TABLET | 25 mg | Y | PA Document | |
| 62135048890 | DIETHYLPROPION HCL | diethylpropion HCl | TABLET | 25 mg | Y | PA Document | |
| 00527147701 | DIETHYLPROPION HCL ER | diethylpropion HCl | TABLET ER | 75 mg | Y | PA Document | |
| 62135048930 | DIETHYLPROPION HCL ER | diethylpropion HCl | TABLET ER | 75 mg | Y | PA Document | |
| 00143914401 | LIRAGLUTIDE | liraglutide | PEN INJCTR | 0.6 mg/0.1 mL (18 mg/3 mL) | Y | Y | PA Document |
| 00143914402 | LIRAGLUTIDE | liraglutide | PEN INJCTR | 0.6 mg/0.1 mL (18 mg/3 mL) | Y | Y | PA Document |
| 00143914403 | LIRAGLUTIDE | liraglutide | PEN INJCTR | 0.6 mg/0.1 mL (18 mg/3 mL) | Y | Y | PA Document |
| 00480366719 | LIRAGLUTIDE | liraglutide | PEN INJCTR | 0.6 mg/0.1 mL (18 mg/3 mL) | Y | Y | PA Document |
| 00480366720 | LIRAGLUTIDE | liraglutide | PEN INJCTR | 0.6 mg/0.1 mL (18 mg/3 mL) | Y | Y | PA Document |
| 00480366722 | LIRAGLUTIDE | liraglutide | PEN INJCTR | 0.6 mg/0.1 mL (18 mg/3 mL) | Y | Y | PA Document |
| 71288056383 | LIRAGLUTIDE | liraglutide | PEN INJCTR | 0.6 mg/0.1 mL (18 mg/3 mL) | Y | Y | PA Document |
| 71288056384 | LIRAGLUTIDE | liraglutide | PEN INJCTR | 0.6 mg/0.1 mL (18 mg/3 mL) | Y | Y | PA Document |
| 71288056385 | LIRAGLUTIDE | liraglutide | PEN INJCTR | 0.6 mg/0.1 mL (18 mg/3 mL) | Y | Y | PA Document |
| 00480725019 | LIRAGLUTIDE | liraglutide | PEN INJCTR | 3 mg/0.5 mL (18 mg/3 mL) | Y | PA Document | |
| 00480725046 | LIRAGLUTIDE | liraglutide | PEN INJCTR | 3 mg/0.5 mL (18 mg/3 mL) | Y | PA Document | |
| 00169280015 | SAXENDA | liraglutide | PEN INJCTR | 3 mg/0.5 mL (18 mg/3 mL) | N | Y | PA Document |
| 61269056590 | ORLISTAT | orlistat | CAPSULE | 120 mg | Y | PA Document | |
| 61269046090 | XENICAL | orlistat | CAPSULE | 120 mg | Y | PA Document | |
| 72989040930 | PHENDIMETRAZINE TARTRATE ER | phendimetrazine tartrate | CAPSULE ER | 105 mg | Y | PA Document | |
| 10702004510 | PHENDIMETRAZINE TARTRATE | phendimetrazine tartrate | TABLET | 35 mg | Y | PA Document | |
| 10702007701 | PHENDIMETRAZINE TARTRATE | phendimetrazine tartrate | TABLET | 35 mg | Y | PA Document | |
| 10702007710 | PHENDIMETRAZINE TARTRATE | phendimetrazine tartrate | TABLET | 35 mg | Y | PA Document | |
| 10702007810 | PHENDIMETRAZINE TARTRATE | phendimetrazine tartrate | TABLET | 35 mg | Y | PA Document | |
| 64850044001 | PHENDIMETRAZINE TARTRATE | phendimetrazine tartrate | TABLET | 35 mg | Y | PA Document | |
| 64850044010 | PHENDIMETRAZINE TARTRATE | phendimetrazine tartrate | TABLET | 35 mg | Y | PA Document | |
| 69543041010 | PHENDIMETRAZINE TARTRATE | phendimetrazine tartrate | TABLET | 35 mg | Y | PA Document | |
| 69543041011 | PHENDIMETRAZINE TARTRATE | phendimetrazine tartrate | TABLET | 35 mg | Y | PA Document | |
| 10702002601 | PHENTERMINE HCL | phentermine HCl | CAPSULE | 15 mg | Y | PA Document | |
| 10702002610 | PHENTERMINE HCL | phentermine HCl | CAPSULE | 15 mg | Y | PA Document | |
| 11534015701 | PHENTERMINE HCL | phentermine HCl | CAPSULE | 15 mg | Y | PA Document | |
| 11534015703 | PHENTERMINE HCL | phentermine HCl | CAPSULE | 15 mg | Y | PA Document | |
| 68094080250 | PHENTERMINE HCL | phentermine HCl | CAPSULE | 15 mg | Y | PA Document | |
| 68094080270 | PHENTERMINE HCL | phentermine HCl | CAPSULE | 15 mg | Y | PA Document | |
| 10702002701 | PHENTERMINE HCL | phentermine HCl | CAPSULE | 30 mg | Y | PA Document | |
| 10702002710 | PHENTERMINE HCL | phentermine HCl | CAPSULE | 30 mg | Y | PA Document | |
| 10702002801 | PHENTERMINE HCL | phentermine HCl | CAPSULE | 30 mg | Y | PA Document | |
| 10702002810 | PHENTERMINE HCL | phentermine HCl | CAPSULE | 30 mg | Y | PA Document | |
| 11534017601 | PHENTERMINE HCL | phentermine HCl | CAPSULE | 30 mg | Y | PA Document | |
| 11534017603 | PHENTERMINE HCL | phentermine HCl | CAPSULE | 30 mg | Y | PA Document | |
| 60793000901 | PHENTERMINE HCL | phentermine HCl | CAPSULE | 30 mg | Y | PA Document | |
| 68094091050 | PHENTERMINE HCL | phentermine HCl | CAPSULE | 30 mg | Y | PA Document | |
| 68094091070 | PHENTERMINE HCL | phentermine HCl | CAPSULE | 30 mg | Y | PA Document | |
| 10702002901 | PHENTERMINE HCL | phentermine HCl | CAPSULE | 37.5 mg | Y | PA Document | |
| 10702002903 | PHENTERMINE HCL | phentermine HCl | CAPSULE | 37.5 mg | Y | PA Document | |
| 10702002910 | PHENTERMINE HCL | phentermine HCl | CAPSULE | 37.5 mg | Y | PA Document | |
| 11534015901 | PHENTERMINE HCL | phentermine HCl | CAPSULE | 37.5 mg | Y | PA Document | |
| 11534015903 | PHENTERMINE HCL | phentermine HCl | CAPSULE | 37.5 mg | Y | PA Document | |
| 42806052401 | PHENTERMINE HCL | phentermine HCl | CAPSULE | 37.5 mg | Y | PA Document | |
| 57844000910 | ADIPEX-P | phentermine HCl | TABLET | 37.5 mg | Y | PA Document | |
| 57844014001 | ADIPEX-P | phentermine HCl | TABLET | 37.5 mg | Y | PA Document | |
| 57844014056 | ADIPEX-P | phentermine HCl | TABLET | 37.5 mg | Y | PA Document | |
| 10702002501 | PHENTERMINE HCL | phentermine HCl | TABLET | 37.5 mg | Y | PA Document | |
| 10702002510 | PHENTERMINE HCL | phentermine HCl | TABLET | 37.5 mg | Y | PA Document | |
| 11534016001 | PHENTERMINE HCL | phentermine HCl | TABLET | 37.5 mg | Y | PA Document | |
| 11534016003 | PHENTERMINE HCL | phentermine HCl | TABLET | 37.5 mg | Y | PA Document | |
| 11534016030 | PHENTERMINE HCL | phentermine HCl | TABLET | 37.5 mg | Y | PA Document | |
| 31722035901 | PHENTERMINE HCL | phentermine HCl | TABLET | 37.5 mg | Y | PA Document | |
| 43547040410 | PHENTERMINE HCL | phentermine HCl | TABLET | 37.5 mg | Y | PA Document | |
| 43547040411 | PHENTERMINE HCL | phentermine HCl | TABLET | 37.5 mg | Y | PA Document | |
| 51224010150 | PHENTERMINE HCL | phentermine HCl | TABLET | 37.5 mg | Y | PA Document | |
| 53489067601 | PHENTERMINE HCL | phentermine HCl | TABLET | 37.5 mg | Y | PA Document | |
| 53489067610 | PHENTERMINE HCL | phentermine HCl | TABLET | 37.5 mg | Y | PA Document | |
| 64850081001 | PHENTERMINE HCL | phentermine HCl | TABLET | 37.5 mg | Y | PA Document | |
| 64850081010 | PHENTERMINE HCL | phentermine HCl | TABLET | 37.5 mg | Y | PA Document | |
| 68094070270 | PHENTERMINE HCL | phentermine HCl | TABLET | 37.5 mg | Y | PA Document | |
| 10702000109 | LOMAIRA | phentermine HCl | TABLET | 8 mg | Y | PA Document | |
| 62135095990 | PHENTERMINE HCL | phentermine HCl | TABLET | 8 mg | Y | PA Document | |
| 00480229956 | PHENTERMINE-TOPIRAMATE ER | phentermine/topiramate | CPMP 24HR | 11.25 mg-69 mg | Y | PA Document | |
| 43598062630 | PHENTERMINE-TOPIRAMATE ER | phentermine/topiramate | CPMP 24HR | 11.25 mg-69 mg | Y | PA Document | |
| 66993078230 | PHENTERMINE-TOPIRAMATE ER | phentermine/topiramate | CPMP 24HR | 11.25 mg-69 mg | Y | PA Document | |
| 00480329556 | PHENTERMINE-TOPIRAMATE ER | phentermine/topiramate | CPMP 24HR | 15 mg-92 mg | Y | PA Document | |
| 43598062730 | PHENTERMINE-TOPIRAMATE ER | phentermine/topiramate | CPMP 24HR | 15 mg-92 mg | Y | PA Document | |
| 66993078330 | PHENTERMINE-TOPIRAMATE ER | phentermine/topiramate | CPMP 24HR | 15 mg-92 mg | Y | PA Document | |
| 00480329756 | PHENTERMINE-TOPIRAMATE ER | phentermine/topiramate | CPMP 24HR | 3.75 mg-23 mg | Y | PA Document | |
| 43598062430 | PHENTERMINE-TOPIRAMATE ER | phentermine/topiramate | CPMP 24HR | 3.75 mg-23 mg | Y | PA Document | |
| 66993078030 | PHENTERMINE-TOPIRAMATE ER | phentermine/topiramate | CPMP 24HR | 3.75 mg-23 mg | Y | PA Document | |
| 00480329656 | PHENTERMINE-TOPIRAMATE ER | phentermine/topiramate | CPMP 24HR | 7.5 mg-46 mg | Y | PA Document | |
| 43598062530 | PHENTERMINE-TOPIRAMATE ER | phentermine/topiramate | CPMP 24HR | 7.5 mg-46 mg | Y | PA Document | |
| 66993078130 | PHENTERMINE-TOPIRAMATE ER | phentermine/topiramate | CPMP 24HR | 7.5 mg-46 mg | Y | PA Document | |
| 00169452501 | WEGOVY | semaglutide | PEN INJCTR | 0.25 mg/0.5 mL | Y | PA Document | |
| 00169452514 | WEGOVY | semaglutide | PEN INJCTR | 0.25 mg/0.5 mL | Y | PA Document | |
| 00169452590 | WEGOVY | semaglutide | PEN INJCTR | 0.25 mg/0.5 mL | Y | PA Document | |
| 00169452594 | WEGOVY | semaglutide | PEN INJCTR | 0.25 mg/0.5 mL | Y | PA Document | |
| 00169450501 | WEGOVY | semaglutide | PEN INJCTR | 0.5 mg/0.5 mL | Y | PA Document | |
| 00169450514 | WEGOVY | semaglutide | PEN INJCTR | 0.5 mg/0.5 mL | Y | PA Document | |
| 00169450101 | WEGOVY | semaglutide | PEN INJCTR | 1 mg/0.5 mL | Y | PA Document | |
| 00169450114 | WEGOVY | semaglutide | PEN INJCTR | 1 mg/0.5 mL | Y | PA Document | |
| 00169451701 | WEGOVY | semaglutide | PEN INJCTR | 1.7 mg/0.75 mL | Y | PA Document | |
| 00169451714 | WEGOVY | semaglutide | PEN INJCTR | 1.7 mg/0.75 mL | Y | PA Document | |
| 00169452401 | WEGOVY | semaglutide | PEN INJCTR | 2.4 mg/0.75 mL | Y | PA Document | |
| 00169452414 | WEGOVY | semaglutide | PEN INJCTR | 2.4 mg/0.75 mL | Y | PA Document | |
| 72829001001 | IMCIVREE | setmelanotide acetate | VIAL | 10 mg/mL | Y | PA Document | |
| 00002247101 | ZEPBOUND | tirzepatide | PEN INJCTR | 10 mg/0.5 mL | Y | Y | PA Document |
| 00002247180 | ZEPBOUND | tirzepatide | PEN INJCTR | 10 mg/0.5 mL | Y | Y | PA Document |
| 00002246001 | ZEPBOUND | tirzepatide | PEN INJCTR | 12.5 mg/0.5 mL | Y | Y | PA Document |
| 00002246080 | ZEPBOUND | tirzepatide | PEN INJCTR | 12.5 mg/0.5 mL | Y | Y | PA Document |
| 00002245701 | ZEPBOUND | tirzepatide | PEN INJCTR | 15 mg/0.5 mL | Y | Y | PA Document |
| 00002245780 | ZEPBOUND | tirzepatide | PEN INJCTR | 15 mg/0.5 mL | Y | Y | PA Document |
| 00002250601 | ZEPBOUND | tirzepatide | PEN INJCTR | 2.5 mg/0.5 mL | Y | Y | PA Document |
| 00002250680 | ZEPBOUND | tirzepatide | PEN INJCTR | 2.5 mg/0.5 mL | Y | Y | PA Document |
| 00002249501 | ZEPBOUND | tirzepatide | PEN INJCTR | 5 mg/0.5 mL | Y | Y | PA Document |
| 00002249580 | ZEPBOUND | tirzepatide | PEN INJCTR | 5 mg/0.5 mL | Y | Y | PA Document |
| 00002248401 | ZEPBOUND | tirzepatide | PEN INJCTR | 7.5 mg/0.5 mL | Y | Y | PA Document |
| 00002248480 | ZEPBOUND | tirzepatide | PEN INJCTR | 7.5 mg/0.5 mL | Y | Y | PA Document |
| 00002134004 | ZEPBOUND | tirzepatide | VIAL | 10 mg/0.5 mL | Y | PA Document | |
| 00002142304 | ZEPBOUND | tirzepatide | VIAL | 12.5 mg/0.5 mL | Y | PA Document | |
| 00002200204 | ZEPBOUND | tirzepatide | VIAL | 15 mg/0.5 mL | Y | PA Document | |
| 00002015201 | ZEPBOUND | tirzepatide | VIAL | 2.5 mg/0.5 mL | Y | PA Document | |
| 00002015204 | ZEPBOUND | tirzepatide | VIAL | 2.5 mg/0.5 mL | Y | PA Document | |
| 00002024301 | ZEPBOUND | tirzepatide | VIAL | 5 mg/0.5 mL | Y | PA Document | |
| 00002024304 | ZEPBOUND | tirzepatide | VIAL | 5 mg/0.5 mL | Y | PA Document | |
| 00002121404 | ZEPBOUND | tirzepatide | VIAL | 7.5 mg/0.5 mL | Y | PA Document |