Obesity Drugs

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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 but eligible patients will encounter a co-pay at the pharmacy.
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.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
liraglutide SAXENDA PEN INJCTR N   Mar 31, 2016
benzphetamine HCl BENZPHETAMINE HCL TABLET    
diethylpropion HCl DIETHYLPROPION HCL TABLET    
diethylpropion HCl DIETHYLPROPION HCL ER TABLET ER    
lorcaserin HCl BELVIQ XR TAB ER 24H   May 25, 2017
lorcaserin HCl BELVIQ TABLET    
naltrexone HCl/bupropion HCl CONTRAVE TABLET ER    
orlistat XENICAL CAPSULE    
orlistat ALLI CAPSULE    
phendimetrazine tartrate PHENDIMETRAZINE TARTRATE ER CAPSULE ER    
phendimetrazine tartrate PHENDIMETRAZINE TARTRATE TABLET    
phentermine HCl PHENTERMINE HCL CAPSULE    
phentermine HCl ADIPEX-P CAPSULE    
phentermine HCl SUPRENZA ODT TAB RAPDIS    
phentermine HCl PHENTERMINE HCL TABLET    
phentermine HCl LOMAIRA TABLET    
phentermine HCl ADIPEX-P TABLET    
phentermine/topiramate QSYMIA CPMP 24HR