Writing eligibility criteria that hold up

Why BMI thresholds underperform

BMI is the default gate because it is simple, clinically conventional, and easy to administer. It is also the criterion most disconnected from whether a specific member will benefit, and it is trivially soft at the margin — the difference between a BMI of 26.6 and 27.0 is a single office visit.

More importantly, a BMI gate controls *who starts* and nothing else. It exerts no influence on titration, on persistence, or on whether anyone ever stops. Most of your cost is determined after the gate.

Criteria that actually bind

Documented engagement before initiation. Requiring completion of a short structured program before a prescription is written is clinically reasonable, legally defensible, and filters meaningfully for members likely to persist.

Step therapy with written escalation criteria. Trying lower-cost agents first is standard practice across therapeutic categories. The essential detail is that escalation criteria must be explicit and time-bound, or step therapy becomes an indefinite delay and an employee-relations problem.

Continuation review at defined intervals. Coverage continues if the member is engaged and responding. This is the highest-leverage criterion available and the one most often omitted, because it requires the vendor to actually report and act on it.

Plan the appeals path first

Every criterion generates appeals, and appeals handled badly produce the exact employee-relations damage the committee was trying to avoid. Decide in advance who adjudicates, what the turnaround commitment is, and what documentation overturns a denial.

Route appeals to a clinical reviewer, never to HR. The moment a benefits generalist is deciding individual medical necessity, you have both a fairness problem and a liability problem.