Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists Weight Management Benefit for Pediatric Members
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Defines medical necessity and prior authorization criteria for liraglutide (Saxenda), semaglutide (Wegovy), and tirzepatide (Zepbound) when used for chronic weight management in pediatric members under the EPSDT benefit for Ambetter Georgia Medicaid plans.
Added Wegovy tablets formulation to the policy.
Revised age limit to ≥ 10 years (previously ≥ 12 years).
Clarified continued therapy renewal criteria for age ≥ 18 years and added criteria for age < 18 years including achievement or maintenance of BMI reduction.
Added new multi-dose vial and KwikPen dosage forms for Zepbound (tirzepatide).
Added Wegovy HD injection 7.2 mg formulation.
Coverage Criteria and Medical Necessity
Initial Therapy
Covered when ALL of the following are met for an EPSDT weight management request:
Approval duration: 6 months
Continuation Therapy
Covered when ALL of the following are met for continuation:
Approval duration: 12 months or to the member's 21st birthday, whichever is shorter
Coverage criteria (summary from updated sections)
Policy-level coverage decisions and renewal criteria (summarized from updates and appendices in this document):
Revised from previous >= 12 years
Presence of these conditions is exclusionary (see Appendix C)
Continued therapy approval duration updated to 12 months or to the member's 21st birthday, whichever is shorter
Revised Coverage Criteria Highlights
Policy revisions affecting coverage criteria (details available in other sections of the full policy):
Recorded in policy revisions
Recorded in policy revisions
Recorded in policy revisions
These coverage criteria do not apply to orforglipron (Foundayo) because there are insufficient clinical data establishing safety and effectiveness of orforglipron in pediatric patients. Requests for Foundayo for members aged 18–21 years should be reviewed per state guidance for weight management and other applicable policies (for example, formulary exception policies).
Use of GLP-1 receptor agonists is excluded for patients with contraindications listed in Appendix C, including a personal or family history of medullary thyroid carcinoma (MTC), multiple endocrine neoplasia type 2 (MEN 2), or a prior hypersensitivity reaction to liraglutide, semaglutide, tirzepatide, or any excipients. Additionally, MDRP and plan-specific exclusions described in Appendix D and state Medicaid directions may render a requested use excluded for a given member; refer to those appendices for plan-specific handling.
For Medicaid members, when state Medicaid coverage provisions conflict with this clinical policy, state Medicaid coverage provisions take precedence. Providers should consult the applicable state Medicaid manual for any coverage provisions that supersede this policy.
Coadministration of multiple GLP-1 receptor agonists is not recommended. In addition, the safety and effectiveness of liraglutide (Saxenda) in pediatric patients with type 2 diabetes mellitus have not been established; prescribers should consider this limitation when evaluating pediatric requests.
Operationally, therapy may be considered ineffective and subject to discontinuation if the member has achieved <5% weight loss after 3 months of therapy, consistent with the Endocrine Society practice guideline referenced in Appendix D. Programs may use this <5% at 3 months checkpoint to inform decisions about continuing, switching, or discontinuing pharmacologic therapy.
This clinical policy is intended to serve as a guide to medical necessity to assist in coverage decision-making and benefit administration. Specific conditions that are considered not medically necessary (NMN) or additional NMN details are documented elsewhere in the full policy and appendices; following those NMN conditions is required when making final coverage determinations.
Agents, Dosing, and Product Formulations
| liraglutide (Saxenda) | GLP-1 receptor agonist for weight management |
| semaglutide (Wegovy) | GLP-1 receptor agonist for weight management |
| tirzepatide (Zepbound) | GLP-1 receptor agonist for weight management |
| ozempic (semaglutide) | GLP-1 receptor agonist for T2DM (listed as therapeutic alternative) |
| mounjaro (tirzepatide) | GLP-1/GIP receptor agonist for T2DM (listed as therapeutic alternative) |
| Liraglutide (Saxenda) - pre-filled multi-dose pens | 0.6 mg, 1.2 mg, 1.8 mg, 2.4 mg, 3 mg (6 mg/mL, 3 mL) |
| Semaglutide (Wegovy) - prefilled single-dose pens | 0.25 mg, 0.5 mg, 1 mg, 1.7 mg, 2.4 mg; Wegovy HD 7.2 mg |
| Semaglutide (Wegovy) - prefilled single-dose syringes | 0.25 mg, 0.5 mg, 1 mg, 1.7 mg, 2.4 mg |
| Semaglutide (Wegovy) - tablets | 1.5 mg, 4 mg, 9 mg, 25 mg |
| Tirzepatide (Zepbound) - pre-filled single-dose pens | 2.5 mg, 5 mg, 7.5 mg, 10 mg, 12.5 mg, 15 mg |
| Tirzepatide (Zepbound) - pre-filled single-dose vials | 2.5 mg, 5 mg, 7.5 mg, 10 mg, 12.5 mg, 15 mg |
| Tirzepatide (Zepbound) - multi-dose vials | 10 mg/2.4 mL (4.17 mg/mL) for four 2.5 mg/0.6 mL doses; 20 mg/2.4 mL (8.33 mg/mL) for four 5 mg/0.6 mL doses; 30 mg/2.4 mL (12.5 mg/mL) for four 7.5 mg/0.6 mL doses; 40 mg/2.4 mL (16.7 mg/mL) for four 10 mg/0.6 mL doses; 50 mg/2.4 mL (20.8 mg/mL) for four 12.5 mg/0.6 mL doses; 60 mg/2.4 mL (25 mg/mL) for four 15 mg/0.6 mL doses |
| Tirzepatide (Zepbound) - single-patient-use KwikPens | 10 mg/2.4 mL (4.17 mg/mL) for four 2.5 mg/0.6 mL doses; 20 mg/2.4 mL (8.33 mg/mL) for four 5 mg/0.6 mL doses; 30 mg/2.4 mL (12.5 mg/mL) for four 7.5 mg/0.6 mL doses; 40 mg/2.4 mL (16.7 mg/mL) for four 10 mg/0.6 mL doses; 50 mg/2.4 mL (20.8 mg/mL) for four 12.5 mg/0.6 mL doses; 60 mg/2.4 mL (25 mg/mL) for four 15 mg/0.6 mL doses |
Prior Authorization, Documentation, and Operational Steps
Prior authorization required for EPSDT pediatric requests
Prior authorization is required for liraglutide (Saxenda), semaglutide (Wegovy), and tirzepatide (Zepbound) when requested for pediatric weight management under the EPSDT benefit; all requests must meet the policy's initial or continued therapy criteria.
PA updated for age, formulations, and renewal durations
Prior authorization rules have been updated to reflect a revised minimum pediatric age of ≥10 years, new product formulations (including Wegovy HD injection and Wegovy tablets), and revised renewal/approval durations (first approval 6 months; continued approvals up to 12 months or until the member's 21st birthday).
PA impacted by revised clinical criteria and product list
Changes to eligibility (age lowered to ≥10 years), added formulations (e.g., Wegovy tablets, Wegovy HD injection, new Zepbound dosage forms), and clarified continued-therapy requirements will affect prior authorization determinations and renewal decisions.
Saxenda: generic-first (liraglutide) requirement
For requests involving Saxenda, the member must use generic liraglutide (generic Saxenda) unless there is a contraindication, clinically significant adverse effects, or a plan-preferred brand exception per the PDL; document the exception if applicable.
Efficacy checkpoint: <5% at 3 months may indicate inefficacy
Use the Endocrine Society guidance operationally: if weight loss is <5% after 3 months of therapy, the medication may be considered ineffective and discontinuation or alternative therapy should be considered.
Required supporting clinical documentation with PA
Submit supporting clinical documentation with the PA request — examples include office chart notes, laboratory results, and other records that show the member meets all approval criteria and that the request is being made under EPSDT when applicable.
- Office chart notes demonstrating prior 6-month supervised weight loss plan and ongoing engagement in weight management program
- Labs or other clinical data relevant to comorbidities or T2DM management
- Documentation showing prior trials of preferred GLP-1 RA when required
Include BMI calculations and MDRP/plan-specific documentation
Include BMI calculations and supporting clinical information in the submission (BMI = 703 x [weight (lbs)/height (inches)2]). Follow Appendix D and plan-/state-specific MDRP directions that may require additional documentation or alter coverage handling.
- Calculated BMI and method of calculation
- Documentation of obesity-related comorbidities if applicable
- Plan- or state-specific MDRP documentation per Appendix D
Adhere to plan coverage documents and regulatory requirements
Follow the Health Plan's coverage documents and applicable legal/regulatory requirements; this clinical policy is guidance for medical necessity but does not guarantee payment — ensure requests conform to plan terms and administrative policies.
Denial risk if required documentation or criteria not met
Requests that do not include required supporting clinical documentation or that fail to demonstrate the member meets all approval criteria (initial or continued) may be denied.
- Missing documentation of prior supervised 6‑month weight loss program
- Lack of evidence of required weight‑loss response at renewal
Contraindications may lead to denial (MTC, MEN 2, hypersensitivity)
Do not request coverage for members with exclusionary contraindications listed in Appendix C (personal/family history of medullary thyroid carcinoma [MTC], MEN 2, or prior hypersensitivity to liraglutide, semaglutide, or tirzepatide); presence of these contraindications may trigger denial.
Coverage subject to plan terms, exclusions, and limitations
Coverage determinations and benefit administration remain subject to all plan terms, conditions, exclusions, and limitations; use this clinical policy as a medical necessity guide but confirm eligibility and benefits against the member's coverage documents.
Clinical Background and Scope
GLP-1 receptor agonists (liraglutide, semaglutide, tirzepatide) are indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management. For pediatric coverage under EPSDT, this policy outlines age, BMI, prior-treatment, and program participation requirements; coadministration with other GLP-1 agents is not recommended, and agent-specific pediatric safety limitations (for example, liraglutide in pediatric T2DM) should be considered when determining appropriateness of therapy.
Definitions and Calculations
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