Prior authorization and supply limits

Prior authorization is required for GLP‑1 and GLP‑1/GIP agonist medications under this policy; approvals are limited to a 28–30 day supply per fill, mail‑order is excluded, initial approval is 6 months and continuation approvals are 12 months.

• Coverage limited to 28–30 day supply per fill; 75% of days must be exhausted before refill
• Mail‑order pharmacy benefit excluded for GLP‑1/GIP prescriptions
• Initial approval length: 6 months; Continuation approval length: 12 months

Prior authorization required — use MA standard form

All requests require prior authorization; use the Massachusetts Standard Form for Medication Prior Authorization Requests (Form #434) or the eForm and include supporting documentation.

• Use Massachusetts Standard Form for Medication Prior Authorization Requests #434 (print/fax) or the online eForm
• Include required clinical documentation with the submission

Prior authorization submission and contact

Submit medication prior authorization requests using the Massachusetts Standard Form (Form #434) or the eForm; providers may call, fax, or mail supporting clinical information to BCBSMA Pharmacy Operations.

• Fax or mail Form #434 to: Blue Cross Blue Shield of Massachusetts Pharmacy Operations Department, 25 Technology Place, Hingham, MA 02043
• Phone: 1-800-366-7778; Fax: 1-800-583-6289
• Providers may include clinical notes, lab results, and other supporting information by call, fax, or mail

Liraglutide requires prior use of preferred drugs or documented rationale

For liraglutide (Saxenda) requests, the provider must document prior use of preferred drugs and either failure of those agents or a clinical rationale for not using them.

• Document previous use of preferred medications and specifics of treatment failure, or provide clinical rationale for why preferred agents are not appropriate

Step therapy / formulary exception — two‑agent failure required for non‑covered meds

For non‑covered or non‑formulary medications, prior treatment failure with, or contraindication to, at least two covered formulary alternatives is required when available; exceptions may be requested with supporting documentation.

• Provide names and strengths of formulary alternatives tried and specifics regarding treatment failures when requesting an exception
• Exception requests must include clinical documentation to support the need for a non‑formulary agent

Step therapy and formulary placement notes (policy history)

Policy history shows formulary and agent placement changes (e.g., movement of Contrave and Imcivree to another policy and removal of Belviq), which may affect step therapy or coverage pathways for specific members.

• Effective 1/1/2026 GLP‑1/GIP medications are not covered for BCBSMA Focused formulary members (medical necessity review unavailable) — review member formulary before submitting
• Refer to updated policy history for recent additions (oral semaglutide, high‑dose Wegovy) that may change formulary placement

Required baseline and lifestyle documentation — 6‑month trial attestation

Providers must submit physician attestation or documentation of engagement in a comprehensive weight‑loss plan for at least 6 months prior to initiation and provide baseline BMI/weight (and BMI% for pediatrics).

• Attest to a 6‑month trial of reduced‑calorie diet, increased physical activity, and behavioral modifications prior to initiation
• Include baseline BMI and weight; for pediatrics include baseline BMI% and documentation weight >60 kg where applicable

Continuation documentation — weight loss, adherence, tolerability

For continuation requests, provide documentation of significant weight loss (e.g., ≥4% of baseline at 16 weeks for liraglutide or meeting the applicable agent threshold), adherence and tolerability for ≥3 consecutive months, and ongoing participation in a comprehensive weight management plan.

• Liraglutide: ≥4% weight loss of baseline at 16 weeks OR continued weight loss OR maintenance of achieved weight
• Document adherence and tolerating maintenance dose for at least 3 consecutive months
• For Wegovy/Zepbound, use the agent‑specific response thresholds (e.g., Wegovy ≥5% at 16 weeks; Zepbound ≥5% at 20 weeks) as applicable

Required documentation and clinician attestation — lifestyle modification

Providers must submit attestation/documentation that the member is actively engaged in a comprehensive lifestyle modification plan (reduced‑calorie diet, increased physical activity, behavioral modifications) and include supporting clinical documentation (chart notes, labs) to show criteria are met.

• Include clinical notes or supporting clinical statements documenting lifestyle engagement
• Attach relevant lab results or diagnostic data when required by indication

MASH diagnostic documentation — fibrosis staging (F2–F3) required

For MASH coverage with subcutaneous Wegovy, submit documentation confirming fibrosis stage F2–F3 by VCTE, MRE, or historical liver biopsy as part of the prior authorization request.

• Acceptable fibrosis confirmation: vibration‑controlled transient elastography (VCTE), magnetic resonance elastography (MRE), or historical liver biopsy
• Also include physician attestation of active engagement in a comprehensive lifestyle modification plan prior to initiation

Required documentation for exception / individual consideration

Exception (individual consideration) requests must include supporting clinical documentation such as chart notes, lab results, specifics of prior formulary alternatives tried and failed, and relevant peer‑reviewed literature or compendia references.

• Provide the name and strength of formulary alternatives tried and failed and specifics regarding the treatment failure
• Include clinical literature or references from AHFS‑DI, Lexi‑Drug, Clinical Pharmacology, Micromedex/Drugdex, or nationally recognized guidelines

Focused formulary exclusion — no medical necessity review for Focused formulary members

Medical necessity review is not available for members on the BCBSMA Focused formulary; requests for GLP‑1/GLP‑1‑GIP agents for those members will be denied as not a covered benefit.

• Verify the member's formulary (Focused vs standard) prior to submission — do not submit individual consideration for Focused formulary members

Documentation‑based denials — risk when documentation is missing or based on samples

Requests lacking supporting documentation (e.g., chart notes, labs, required prior treatment failure details) or requests based exclusively on samples may be denied and will not meet exception criteria.

• Do not base requests solely on sample use; include objective clinical documentation
• Ensure documentation of prior treatment failures includes specifics (agent, dose, dates, reason for discontinuation)

Denial triggers and exception pathway — submit individual consideration when criteria unmet

Requests that do not meet the policy's coverage criteria may be denied; providers are encouraged to submit an individual consideration/exception request with supporting clinical documentation when standard criteria are unlikely to be clinically effective.

• If criteria are not met, include thorough clinical rationale and supporting documentation when requesting individual consideration
• For non‑covered medications, document prior failure or contraindication to at least two covered formulary alternatives when available