Obesity is a serious health issue that often involves comorbid conditions such as diabetes, heart disease, and high blood pressure. As more patients seek help managing their weight, the use of medications is becoming more common. However, these medications aren’t right for everyone. That’s why it’s essential to understand each patient’s medical background when requesting prior authorization.

Complete clinical information allows reviewers to make well-informed coverage decisions for weight-loss medications and may reduce requests for additional documentation or appeals. Because requirements vary by medication, indication, and benefit plan, providers should submit information that addresses the applicable coverage criteria.

Information to include

When submitting a prior authorization request for weight loss medication, providers should include the following information, as applicable:

• Current and baseline height, weight, and body mass index (BMI).
• Diagnosis and relevant weight-related health conditions.
• Previous weight-management interventions and outcomes, including diet, physical activity, behavioral modification, and prior therapies, as applicable.
• Any additional clinical information required by the applicable drug-specific coverage policy or the patient’s benefit plan.

Complete and accurate documentation helps demonstrate that the requested medication is appropriate for the patient’s needs and meets applicable Cigna Healthcare^® coverage criteria.*

Before submitting the request

Before submission, providers should verify the patient’s eligibility, pharmacy benefits, and coverage requirements and confirm that the request addresses the criteria for the medication and indication.

Why it’s important

Well-informed and complete requests can minimize denials and the need for providers to submit additional details through the appeal process.

The bigger picture

Tackling obesity requires more than just medication; it takes a full understanding of each patient’s situation. By sharing complete and accurate clinical information, providers can help ensure patients get the right treatment while supporting informed and timely coverage decisions.

For more information, including coverage policies for weight-loss medications, please visit the Cigna for Health Care Professionals website (CignaforHCP.com) and navigate to Resources > Coverage Policies > Drug Policy A-Z Index.

*Coverage varies by benefit plan and may depend on the medication’s indication and applicable prior authorization criteria.