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.
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 PA Document Mar 31, 2016
benzphetamine HCl BENZPHETAMINE HCL TABLET PA Document  
diethylpropion HCl DIETHYLPROPION HCL TABLET PA Document  
diethylpropion HCl DIETHYLPROPION HCL ER TABLET ER PA Document  
naltrexone HCl/bupropion HCl CONTRAVE TABLET ER PA Document  
orlistat XENICAL CAPSULE PA Document  
phendimetrazine tartrate PHENDIMETRAZINE TARTRATE ER CAPSULE ER PA Document  
phendimetrazine tartrate PHENDIMETRAZINE TARTRATE TABLET PA Document  
phentermine HCl PHENTERMINE HCL CAPSULE PA Document  
phentermine HCl ADIPEX-P CAPSULE PA Document  
phentermine HCl LOMAIRA TABLET PA Document  
phentermine HCl ADIPEX-P TABLET PA Document  
phentermine HCl PHENTERMINE HCL TABLET PA Document  
phentermine/topiramate QSYMIA CPMP 24HR PA Document  
semaglutide WEGOVY PEN INJCTR PA Document  
setmelanotide acetate IMCIVREE VIAL PA Document Apr 01, 2021