GLP-1 Clinical Criteria Framework
- 1BMI threshold: BMI ≥30 (obesity) or BMI ≥27 with at least one weight-related comorbidity (diabetes, hypertension, sleep apnea)
- 2Comorbidity documentation: Documented comorbidity for BMI 27–29.9
- 3Lifestyle intervention: Documented participation in a behavioral weight management program
- 4Prior authorization: Clinical review before approving GLP-1 prescription
- 5Monitoring: Regular follow-up (every 3–6 months) to assess response and continued appropriateness
- 6Discontinuation criteria: Discontinue if <5% weight loss after 12 weeks of treatment
Step Therapy
Step therapy for GLP-1 drugs — requiring documented participation in a lifestyle intervention program before approving GLP-1 — is both clinically appropriate and cost-effective. Lifestyle interventions (the CDC-recognized Diabetes Prevention Program) produce 5–7% weight loss on average — enough to improve health outcomes for many patients. Members who achieve adequate weight loss through lifestyle intervention do not need GLP-1 drugs.
Discontinuation Criteria
IQ Insight
Discontinuation criteria — stopping GLP-1 therapy for members who do not achieve adequate response — are essential for cost management. A member who has not lost at least 5% of body weight after 12 weeks of GLP-1 therapy is unlikely to achieve meaningful weight loss with continued therapy. Discontinuation criteria prevent indefinite GLP-1 use for non-responders.