Blue Cross MA anti‑obesity drugs Coverage Update

Medication-Specific Coverage Criteria

Initial Therapy — Contrave

Contrave (naltrexone/bupropion) covered when ALL of the following are met

Age: Member is 18 years of age or older

Prior lifestyle trial: Physician attestation or documentation that the member has already engaged in at least a 6-month trial of a comprehensive weight loss plan that includes a reduced calorie diet, increased physical activity, and behavioral modifications prior to initiation of therapy6 months

Adjunct use: Physician attestation or documentation that the member will be using medication as an adjunct to a comprehensive weight management plan including a reduced-calorie diet, increased physical activity and behavioral modifications

BMI criteria

BMI options: a. BMI ≥30 kg/m2 OR b. BMI ≥27 kg/m2 with at least one weight-related comorbid condition

Continuation Therapy — Contrave

Continuation criteria for Contrave — renewal allowed when ALL are met

Weight response: Documentation of significant weight loss by meeting ONE: a) documented weight loss of at least 5% of baseline body weight after initiation (first 12 weeks), OR b) demonstrated continued weight loss, OR c) maintained plateau weight at least 5% below baseline5%

Adherence and tolerability: Documentation that the patient is adherent to therapy and has been tolerating the recommended maintenance dose of medication for at least 3 consecutive months3 months

Continued behavioral program: Documentation that the patient continues with a comprehensive weight management plan including a reduced-calorie diet, increased physical activity and behavioral modifications

Initial and Renewal Therapy — Imcivree

Imcivree (setmelanotide) initial and renewal coverage criteria (monogenic/syndromic obesity)

Diagnosis: Patient has a diagnosis of obesity: adults (≥18 years) BMI ≥30 kg/m2 OR pediatric patients ≥2 years of age

Approval duration initial = 4 months

Genetic confirmation OR syndrome: Obesity due to a homozygous or presumed compound heterozygous variant in POMC, PCSK1, or LEPR confirmed by genetic testing with variants interpreted as pathogenic, likely pathogenic, or VUS, OR documentation of monogenic or syndromic obesity due to Bardet-Biedl syndromegenetic testing

Adherence: Demonstration of treatment adherence for continuation

First renewal response:

Initial and Continuation Therapy — Saxenda

Saxenda (liraglutide) initial and continuation criteria

Indication and age/weight: Used for chronic weight management in ONE: a) age 12–17 with body weight >60 kg (include baseline BMI, baseline weight, and BMI % for pediatrics), OR b) adults with initial BMI ≥30 kg/m2, OR c) adults with initial BMI ≥27 kg/m2 with at least one weight-related comorbidity

Prior lifestyle trial: Documentation of a 6-month trial of a comprehensive weight loss plan prior to initiation of therapy6 months

Continuation response:

Initial Therapy - Saxenda

Saxenda may be considered medically necessary when ALL of the following are met

Saxenda Initial Approval: 1) Is being used for chronic weight management in an eligible patient (see Saxenda age/BMI criteria); 2) Physician attestation or documentation of a 6-month trial of a comprehensive weight loss plan prior to initiation; 3) Physician attestation or documentation that medication will be used as an adjunct to a comprehensive weight management plan

From policy: documentation and attestations required prior to initiation.

Continuation Therapy - Saxenda

Renewal of Saxenda coverage if ALL the following are met

Saxenda Continuation: 1) Documentation of significant weight loss by meeting ONE: (a) ≥4% of baseline body weight after initiation (first 16 weeks), OR (b) continued weight loss, OR (c) maintained plateau weight achieved with diet/exercise; AND 2) Documentation that the patient is adherent to therapy and has been tolerating the recommended maintenance dose of medication for at least 3 consecutive months; AND 3) Documentation that the patient continues with a comprehensive weight management plan

Initial Therapy - Wegovy

Wegovy may be considered medically necessary when ALL of the following are met

Wegovy Initial Approval - chronic weight management: 1) Used for chronic weight management in ONE: (a) pediatric 12–17 with initial BMI ≥95th percentile for age/gender (include baseline BMI, weight, BMI %), OR (b) adults with initial BMI ≥30 kg/m2, OR (c) adults with initial BMI ≥27 kg/m2 with at least one weight-related comorbidity; AND 2) Physician attestation/documentation that the member has engaged in a 6-month trial of a comprehensive weight loss plan prior to initiation; AND 3) Physician attestation/documentation that medication will be used as an adjunct to a comprehensive weight management plan

Wegovy - MACE indication

Wegovy may be considered medically necessary to reduce risk of major adverse cardiovascular events (MACE) when ALL of the following are met

Wegovy MACE Initial Approval: 1) Patient is 45 years of age or older; AND 2) Patient is at least 18 years old; AND 3) Patient has BMI >27; AND 4) Patient has established cardiovascular disease defined as one of: prior MI, prior stroke, or symptomatic PAD evidenced by intermittent claudication with ABI <0.85, prior peripheral arterial revascularization, or prior amputation due to ASCVD; AND 5) Patient is receiving standard of care treatment as appropriate (examples: antiplatelet agent, lipid-lowering drug, antihypertensive); AND 6) Patient is not NYHA class IV heart failure

Wegovy - MASH indication

Wegovy may be considered medically necessary for MASH when ALL of the following are met

Wegovy MASH Initial Approval: 1) Diagnosis of metabolic dysfunction-associated steatohepatitis (MASH) with moderate to advanced liver fibrosis (F2–F3) confirmed by VCTE, MRE, or historical liver biopsy; AND 2) Physician attestation/documentation that the member is actively engaged in a comprehensive lifestyle modification plan (reduced calorie diet, increased physical activity, behavioral modifications) prior to initiation

Continuation Therapy - Wegovy (obesity)

Renewal of Wegovy for obesity if ALL the following are met

Wegovy Continuation - obesity: 1) Patient is on the 2.4 mg or 1.7 mg dose; AND 2) Documentation of significant weight loss by meeting ONE: (a) documented weight loss of at least 5% of baseline body weight after initiation (first 16 weeks), OR (b) continued weight loss, OR (c) maintained plateau weight achieved with diet/exercise; AND 3) Documentation that the patient is adherent to therapy and has been tolerating the recommended maintenance dose of medication for at least 3 consecutive months; AND 4) Documentation that the patient continues with a comprehensive weight management plan

Continuation Therapy - Wegovy (MACE)

Renewal of Wegovy for MACE risk reduction if ALL the following are met

Wegovy Continuation - MACE: 1) Individual continues to meet initial approval criteria; AND 2) Individual is adherent to therapy as evidenced by claims records demonstrating >80% fill rate; AND 3) Individual has not developed Type 2 Diabetes or NYHA class IV heart failure; AND 4) Member remains on Standard of Care therapies for cardiovascular disease>80% fill rate

Continuation Therapy - Wegovy (MASH)

Renewal of Wegovy for MASH if ALL the following are met

Wegovy Continuation - MASH: 1) Patient has achieved or maintained a positive clinical response to therapy (e.g., MASH resolution with no worsening of liver fibrosis or improvement in liver fibrosis); AND 2) Physician attestation/documentation that the member is actively engaged in a comprehensive lifestyle modification plan (reduced calorie diet, increased physical activity, behavioral modifications)

Initial Therapy - Zepbound

Zepbound (tirzepatide) may be considered medically necessary when ALL of the following are met

Zepbound Initial Approval: 1) Member is 18 years of age or older; AND 2) Physician attestation or documentation that the member has engaged in at least a 6-month trial of a comprehensive weight loss plan prior to initiation; AND 3) Physician attestation or documentation that the member will be using medication as an adjunct to a comprehensive weight management plan; AND 4) Used for chronic weight management in patients meeting ONE: (a) BMI ≥30 kg/m2, OR (b) BMI ≥27 kg/m2 with at least one weight-related comorbidity

Continuation Therapy - Zepbound

Renewal of Zepbound for obesity if ALL the following are met

Zepbound Continuation: 1) Patient is on 5 mg, 10 mg, or 15 mg dose; AND 2) Documentation of significant weight loss by meeting ONE: (a) documented weight loss of at least 5% of baseline body weight after initiation (first 20 weeks), OR (b) continued weight loss, OR (c) maintained plateau weight achieved with diet/exercise; AND 3) Documentation that the patient is adherent to therapy and has been tolerating the recommended maintenance dose of medication for at least 3 consecutive months; AND 4) Documentation that the patient continues with a comprehensive weight management plan

This policy applies to Blue Cross Blue Shield of Massachusetts commercial members and does not apply to Medicare Advantage members.

Per prior policy updates, Belviq (lorcaserin) and Belviq XR are no longer covered; the FDA withdrew these products from the market and the policy history reflects their removal and noncoverage status.

Continuation of therapy will not be considered medically necessary if the member fails to meet the policy’s required weight-loss or adherence criteria. Specifically, renewal requires documented achievement of the applicable weight-loss threshold (for example, ≥4% of baseline body weight at 16 weeks for Saxenda or ≥5% of baseline body weight at the policy-specified assessment for Wegovy/Zepbound), evidence of adherence and tolerating the recommended maintenance dose for at least 3 consecutive months, and ongoing participation in a comprehensive weight management plan; absence of these documentation elements may result in nonrenewal.

Clinical Thresholds, BMI and Outcome Targets

BMI thresholds (agent-specific / pediatric notes)

Adult BMI thresholdInitial BMI ≥30 kg/m2 for adults

Adult overweight with comorbidity thresholdInitial BMI ≥27 kg/m2 in presence of at least one weight‑related comorbid condition (e.g., hypertension, dyslipidemia, type 2 diabetes)

Pediatric thresholds (general agents)For selected agents (e.g., Wegovy, Saxenda): age 12–17 with BMI ≥95th percentile (Wegovy) or age 12–17 with body weight >60 kg and documentation of baseline BMI and BMI% (Saxenda)

Weight loss thresholds (by agent)

Saxenda weight‑loss thresholdAt least 4% of baseline body weight after initiation (first 16 weeks) to qualify for continuation

Wegovy weight‑loss thresholdDocumented weight loss of at least 5% of baseline body weight after initiation (first 16 weeks) or continued weight loss/maintenance to qualify for continuation

Prior Authorization, Documentation and Refill Rules

Prior Authorization

Prior authorization required — submission channels and form

Prior authorization is required for the medications covered by this policy. Requests may be submitted to Blue Cross Blue Shield of Massachusetts Pharmacy Operations by phone, fax, or mail using the Formulary Exception/Prior Authorization form (contact and address provided).

Pharmacy Operations: Tel: 1-800-366-7778; Fax: 1-800-583-6289
Mailing address: Blue Cross Blue Shield of Massachusetts Pharmacy Operations Department, 25 Technology Place, Hingham, MA 02043
Use the Formulary Exception/Prior Authorization form to request coverage

Prior Authorization

Prior authorization requirements — 6-month lifestyle trial and adjunct use

Prior authorization requires a physician attestation or documentation that the member has engaged in a 6-month trial of a comprehensive weight loss plan and that the medication will be used as an adjunct to that plan; baseline BMI/weight must also be documented as applicable to the agent.

Comprehensive weight loss plan must include reduced-calorie diet, increased physical activity, and behavioral modifications

Policy Scope and Rationale

This policy defines coverage criteria for chronic weight management pharmacotherapy for adults and select pediatric patients. It specifies age and BMI eligibility, requires a physician attestation or documentation of a prior 6-month comprehensive weight loss plan before initiation, and outlines agent-specific initial and continuation requirements (including genetic testing criteria for agents such as Imcivree). The policy also documents exclusions and historical changes — for example, it excludes Medicare Advantage and records prior removals of agents like Belviq, and it has been updated to add indications (such as Wegovy for MASH) and new agents (e.g., Zepbound).

Key Definitions

Obesity (adult) definition

Obesity (adult) definitionAdult patients (≥18 years): BMI ≥30 kg/m2

Obesity (pediatric) notePediatric patients may qualify per agent-specific criteria (e.g., Imcivree for patients ≥2 years; Wegovy/Saxenda per pediatric thresholds)

Overweight with comorbidity definition

Overweight with comorbidity definitionInitial BMI ≥27 kg/m2 in the presence of at least one weight‑related comorbid condition (e.g., hypertension, dyslipidemia, type 2 diabetes)

Documentation requiredProvide baseline BMI and evidence of the weight‑related comorbidity when used to meet eligibility

Established cardiovascular disease (for MACE indication)

OpenPayer

Pharmacy coverage for anti-obesity medications (GLP-1/GIP and others)

Medication-Specific Coverage Criteria

Clinical Thresholds, BMI and Outcome Targets

Prior Authorization, Documentation and Refill Rules

Policy Scope and Rationale

Key Definitions