Weight Management 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.

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Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria Carveout
‐ Bill FFS
New Drug Evaluation & Updates
tirzepatide ZEPBOUND KWIKPEN PEN INJCTR Y Pharmacy PA  
tirzepatide ZEPBOUND PEN INJCTR Y Pharmacy PA Apr 03, 2025
liraglutide LIRAGLUTIDE PEN INJCTR N Pharmacy PA  
liraglutide SAXENDA PEN INJCTR N Pharmacy PA Mar 31, 2016
benzphetamine HCl BENZPHETAMINE HCL TABLET Pharmacy PA  
diethylpropion HCl DIETHYLPROPION HCL TABLET Pharmacy PA  
diethylpropion HCl DIETHYLPROPION HCL ER TABLET ER Pharmacy PA  
orforglipron calcium FOUNDAYO TABLET Pharmacy PA  
orlistat ORLISTAT CAPSULE Pharmacy PA  
orlistat XENICAL CAPSULE Pharmacy PA  
phendimetrazine tartrate PHENDIMETRAZINE TARTRATE ER CAPSULE ER Pharmacy PA  
phendimetrazine tartrate PHENDIMETRAZINE TARTRATE TABLET Pharmacy PA  
phentermine HCl PHENTERMINE HCL CAPSULE Pharmacy PA  
phentermine HCl PHENTERMINE HCL TABLET Pharmacy PA  
phentermine HCl LOMAIRA TABLET Pharmacy PA  
phentermine HCl ADIPEX-P TABLET Pharmacy PA  
phentermine/topiramate PHENTERMINE-TOPIRAMATE ER CPMP 24HR Pharmacy PA  
semaglutide WEGOVY PEN INJCTR Pharmacy PA Feb 05, 2026
semaglutide WEGOVY HD PEN INJCTR Pharmacy PA  
semaglutide WEGOVY TABLET Pharmacy PA  
setmelanotide acetate IMCIVREE VIAL Pharmacy PA Apr 01, 2021
tirzepatide ZEPBOUND VIAL Pharmacy PA Apr 03, 2025