Prior authorization required; Approval lengths

Prior authorization is required for all GLP-1 and GLP-1/GIP agonist requests. Initial approvals are for 6 months and continuation approvals are for 12 months; coverage is limited to a 28–30 day supply per fill with refills allowed after 75% of days exhausted.

• Submit prior authorization using the Massachusetts Standard Form (eForm) or paper Form #434 (see PA instructions).

Use Massachusetts Standard PA form for all requests

All requests must meet the payer's prior authorization requirement and be submitted using the Massachusetts Standard Form for Medication Prior Authorization Requests (eForm) or paper Form #434.

• Include clinical documentation to support requests and any exception rationale.

PA submission method — eForm or Form #434 required

Prior authorization requests must be submitted via the Massachusetts Standard Form (eForm) or mailed/faxed using Form #434; include supporting clinical documentation when requesting exceptions.

• Providers may call, fax, or mail the completed form to BCBSMA Pharmacy Operations (contact information in policy).

Prior use of preferred drugs required for liraglutide

For liraglutide (Saxenda) requests, provider must document prior use of preferred drugs and failure, or provide a clinical rationale for not using preferred medications (e.g., Saxenda and Wegovy).

• State prior preferred agents tried, dosing, duration, and reason for discontinuation or contraindication.

Prior failure with ≥2 formulary alternatives required for non‑covered drugs

For non-covered medications, the provider must document that the member had prior treatment failure with, or contraindication to, at least two covered formulary alternatives before an exception will be considered.

• Include names, strengths, durations, and specific reasons for treatment failure or contraindication for each formulary alternative tried.

Document prior failures with 2 formulary alternatives

Requests for non‑covered medications require documentation of prior treatment failure with, or contraindication to, at least two covered formulary alternatives when available; include specifics of each prior failure.

• Provide treatment dates, doses, and objective evidence of failure (e.g., intolerable adverse events, lack of efficacy).

Attest to prior 6‑month comprehensive weight loss plan

Provider must submit a physician attestation or documentation that the member completed a prior 6‑month comprehensive weight loss plan (reduced calorie diet, increased activity, behavioral modifications) and that medication will be used as an adjunct.

• Attestation must state participation and dates of the 6‑month program.

Include baseline BMI/weight and supporting clinical data

Submit baseline clinical data with the PA: baseline BMI and weight for adults, and baseline BMI, weight and BMI percent for pediatric requests; include chart notes and relevant laboratory results.

• For pediatrics (liraglutide or subcutaneous Wegovy), include BMI % standardized for age/gender.
• Include recent labs or imaging if relevant to indications (e.g., MASH evaluation).

Attach chart notes, labs, and details of alternatives tried

Provide supporting clinical documentation such as chart notes, lab results, clinical notes, and the names and strengths of formulary alternatives tried and failed to demonstrate the member meets all approval criteria.

• Attach clinical literature or guideline references for exception requests when applicable.

Denied for BCBSMA Focused Formulary members — not a covered benefit

Requests for members with the BCBSMA Focused Formulary will be denied because GLP‑1 and GLP‑1/GIP medications for obesity and other FDA‑approved indications are not a covered benefit for those members.

• The medical necessity review process is not available for Focused Formulary members.

Incomplete documentation may lead to denial

Requests missing supporting documentation (chart notes, labs, or other clinical information) that demonstrate the member met the approval criteria may be denied.

• Ensure documentation shows BMI eligibility, prior 6‑month weight‑loss plan, adherence/tolerability, and required prior trials where applicable.

Denial risk: unmet PA or missing prior‑failure documentation

Requests that do not meet prior authorization requirements or that lack documentation of required prior treatment failures (including the requirement for at least two formulary alternative failures for non‑covered drugs) may be denied.

• Verify PA form completion, inclusion of required supporting documents, and documented prior therapy failures or contraindications before submission.