CurrentCignaPolicy N/A

Saxenda, Wegovy, Zepbound (GLP-1 / GLP-1/GIP agents) coverage criteria

Defines medical necessity criteria, initial and continuation approval durations, FDA-approved indications (weight loss, CV risk reduction, obstructive sleep apnea, MASH/NASH), exclusions (concomitant GLP-1/GLP-1GIP use), documentation and prescribing specialist requirements for liraglutide [Saxenda/generic], semaglutide [Wegovy injection & tablet], and tirzepatide [Zepbound].

Policy Summary

PayerCigna

PolicySaxenda, Wegovy, Zepbound (GLP-1 / GLP-1/GIP agents) coverage criteria

Policy CodePolicy N/A

Change TypeMultiple additions and revisions (material)

Effective Date

Next Review Date

Key ActionSubmit prior authorization with required documentation (baseline BMI, behavioral therapy, sleep study, fibrosis staging) for Saxenda, Wegovy (tablet and injection), or Zepbound.

POLICY UPDATE CHANGES

Zepbound was added to the policy with new criteria (initial approval 8 months, continuation 1 year).

Baseline BMI definitions were changed to require baseline (prior to any GLP-1 or GLP-1/GIP agonist) rather than current BMI in several criteria across agents.

Continuation and dosing-related criteria for Wegovy and Zepbound were removed or simplified; approval durations standardized to 1 year for patients currently receiving therapy.

Wegovy indication for Major Adverse Cardiovascular Event(s) risk reduction in patients with established cardiovascular disease was added.

Wegovy indication for MASH/NASH was added with fibrosis staging documentation requirements.

Concomitant use exclusion reworded to specify GLP-1/GIP receptor agonists and to clarify concomitant use with FDA-approved weight-loss medications is not recommended.

Policy statement added gender-definition note indicating use of biological sex for criteria where asterisked.

References updated to include both Wegovy injection and Wegovy tablet across multiple criteria and notes.

Continuation criteria clarified to require completion of ≥1 year of Wegovy injection and/or Wegovy tablet and no worsening of fibrosis or MASH/NASH per prescriber.

Initial therapy approval duration for Wegovy tablet changed from 6 months to 7 months.

Baseline BMI requirement for OSA in obesity changed from 'current BMI ≥30' to 'at baseline, BMI ≥30'.

Baseline definition for patients currently receiving Zepbound was broadened to reference baseline prior to any GLP-1 or GLP-1/GIP agonist (instead of prior to Zepbound only).

3Targeted agents (Saxenda, Wegovy, Zepbound)

≥27Baseline BMI threshold with comorbidity

≥30Baseline BMI threshold without comorbidity

5%General continuation weight loss threshold

10%Zepbound OSA continuation threshold

Coverage Summary

Saxenda, Wegovy, Zepbound - Weight Loss in an Adult with Overweight or Obesity (Initial Therapy and Continuation)

Covered when ANY of the following criteria groups (A or B) are met. Baseline BMI definitions, behavioral therapy requirement, and continuation thresholds are required. Notes on baseline definitions for OSA and Zepbound are included.

ANY of the following

A. Initial Therapy - Saxenda, Wegovy injection, Wegovy tablet, or Zepbound
- Diagnosis of overweight or obesity documented in the medical record
  See baseline BMI definitions below for condition-specific thresholds.
- - ANY of the following
    BMI ≥ 30 kg/m2 (obesity)
    BMI ≥ 27 kg/m2 with at least one weight-related comorbidity (e.g., hypertension, dyslipidemia, OSA, type 2 diabetes)
- Documented, initiated, or planned comprehensive behavioral weight-management program (reduced-calorie diet and increased physical activity) with clinician attestation
  Behavioral therapy must be ongoing during pharmacotherapy initiation.
- For Wegovy tablet initial therapy specifically: prescriber documents intent for weight reduction or CV risk reduction per labeling and plans for appropriate dose escalation to maintenance 25 mg QD, or plans to switch to Wegovy SC if 25 mg QD not tolerated
  Wegovy tablet initial therapy criteria are additive to the general initial therapy requirements.
- For Wegovy MACE Risk Reduction (secondary prevention): patient is an adult with established cardiovascular disease as defined by prior MI, prior stroke, or symptomatic peripheral arterial disease AND baseline BMI ≥ 27 kg/m2
  Wegovy intended for reduction in MACE when added to standard of care; document established CV disease.
- For Obstructive Sleep Apnea (OSA) indication with Zepbound: baseline BMI meets obesity criteria and OSA is moderate to severe documented by sleep study and clinical evaluation
  Baseline BMI definition for OSA: use the general BMI obesity threshold (≥ 30 kg/m2) unless benefit plan or labeling specifies otherwise; include sleep study result and clinician assessment.
B. Continuation Therapy - Renewal after initial treatment period
- Documentation of adherence to the prescribed GLP-1 or GLP-1/GIP agonist regimen and ongoing participation in behavioral weight-management program
- - ANY of the following
    Relative weight reduction ≥ 5% from baseline after 12 weeks on a therapeutic maintenance dose (agent-specific timing may vary per labeling)
    Or, for agents with labeling-specified thresholds: liraglutide (Saxenda): ≥ 4% weight loss after 16 weeks on maintenance dose; Wegovy injection/tablet: documented clinically meaningful weight loss per prescriber assessment consistent with labeling; Zepbound: documented weight reduction and/or improvement in OSA clinical metrics when used for OSA indication
- If patient has not met the required weight-loss threshold by the specified timepoint, therapy is not continued unless prescriber documents clinical rationale that further benefit is likely (e.g., recent dose escalation not yet at maintenance or tolerability issues)
Operational and baseline-definition notes
- Baseline is defined as the most recent, documented weight and BMI prior to initiation of therapy (record the date and values). For purposes of continuity and response assessment, baseline values should be from within 12 weeks prior to treatment start unless clinical circumstances justify older documentation.
- Specific note for Zepbound baseline: the 2.5 mg initiation dose is not a chronic maintenance dose; baseline for Zepbound response assessment should be the weight/BMI recorded prior to initiation of therapy and documented sleep-study results for OSA indication. For OSA, include apnea–hypopnea index (AHI) or respiratory disturbance index (RDI) and severity classification to substantiate moderate-to-severe OSA.
- For Wegovy MACE indication: baseline BMI must be ≥ 27 kg/m2 and documented established cardiovascular disease as defined in labeling (prior MI, prior stroke, or symptomatic peripheral arterial disease). Document CV history and dates of relevant events or procedures.

ALL of the following

Exclusion: Concomitant use of more than one GLP-1 or GLP-1/GIP agonist is not covered (do not coadminister agents).

Wegovy — Major Adverse Cardiovascular Event (MACE) Risk Reduction

Wegovy - Major Adverse Cardiovascular Event(s) Risk Reduction (Established CVD) - Combined Initial and Currently Receiving

Approve for 1 year when ALL of the following are met:

Patient is ≥ 18 years of age

At baseline, patient had a BMI ≥ 27 kg/m2≥27 kg/m2

This refers to baseline prior to any GLP-1 or GLP-1/GIP agonist.

Established cardiovascular disease (one of)

Prior myocardial infarction
Prior stroke (does NOT include transient ischemic attack [TIA])

Wegovy — MASH/NASH (Metabolic Dysfunction-Associated Steatohepatitis)

Wegovy - Metabolic Dysfunction-Associated Steatohepatitis (MASH)/NASH

Wegovy is covered for MASH/NASH when initial therapy criteria are met:

Patient is ≥ 18 years of age

Patient does not have cirrhosis (F4) according to prescriber

Documentation confirming stage F2 or F3 fibrosis (one of, with timeframe)

Liver biopsy performed within the 3 years preceding treatment with Rezdiffra or Wegovy [documentation required]≤3 years
Vibration-controlled elastography (VCTE) performed within the 6 months preceding treatment with Rezdiffra or Wegovy [documentation required]

Zepbound — Obstructive Sleep Apnea (Moderate to Severe) in Patients with Obesity

Zepbound - Obstructive Sleep Apnea, Moderate to Severe, in a Patient with Obesity

Approve for 1 year when ONE of the following (A or B) is met:

A) Initial Therapy

Patient is ≥ 18 years of age
At baseline, patient had a BMI ≥ 30 kg/m2≥30 kg/m2
This refers to baseline prior to any GLP-1 or GLP-1/GIP agonist.
Patient has been diagnosed with moderate to severe obstructive sleep apnea
Patient has had a sleep study showing BOTH: (a) diagnosis of moderate to severe OSA; and (b) apnea-hypopnea index (AHI) ≥ 15 events per hour

Continuation Therapy — Wegovy Injection and Tablet

Documentation Required

Prescriber statement on fibrosis/MASH/NASH

For continuation of Wegovy (MASH/NASH or other Wegovy indications), the prescriber must attest that the patient has not had worsening of fibrosis or MASH/NASH. Include this prescriber statement in the documentation submitted for coverage/renewal.

Prescriber attestation that patient has not had progression to cirrhosis (F4) or worsening of fibrosis/MASH/NASH.
Include attestation in chart notes or prior authorization documentation.

Initial Therapy — Wegovy Tablet (Weight Loss)

Wegovy injection alignment: Changes made for Wegovy tablet regarding therapy duration, baseline definitions, and references were mirrored for Wegovy injection. The policy updates Wegovy injection criteria and notes to reflect the same initial approval duration, continuation requirements, and inclusion of Wegovy tablet where applicable.

The MASH/NASH and MACE sections and related documentation requirements were also updated to include both Wegovy injection and Wegovy tablet consistently across criteria and continuation routing.

Prior Authorization

Prior authorization recommended

Prior authorization is recommended for coverage of these agents. When submitting a PA, include baseline BMI (defined as values prior to any GLP-1 or GLP-1/GIP agonist), documentation of prior behavioral modification/dietary restriction for ≥ 3 months, sleep study results when applicable (AHI ≥ 15 events/hour for OSA), and fibrosis staging evidence for MASH/NASH (biopsy ≤3 years or VCTE/MRE/ELF ≤6 months with ELF 9.2–10.5 as applicable).

Include baseline BMI documented prior to any GLP-1 or GLP-1/GIP agonist.
Document ≥ 3 months of behavioral modification/dietary restriction.
Include sleep study report with AHI when OSA indication is claimed.

Conditions Not Covered / Unproven

Denial Risk

Concomitant GLP-1/GLP-1GIP use exclusion

Claims for concurrent use of a GLP-1 agonist with another GLP-1 or GLP-1/GIP agonist are considered not medically necessary and may be denied. Do not combine Saxenda, Wegovy, Zepbound, or other GLP-1/GIP agents (e.g., Mounjaro, Ozempic) — concomitant use is an exclusion.

Concomitant GLP-1/GLP-1GIP therapy is not allowed and is at risk of denial.
Examples include combining Saxenda, Wegovy, Zepbound, Mounjaro, Ozempic, Trulicity, exenatide.

Provider Actions & Documentation Requirements

Prior Authorization

Prior authorization recommended

Prior authorization is recommended for all targeted agents (liraglutide/Saxenda, Wegovy injection and tablet, Zepbound). PA submissions should include patient identifiers, baseline BMI (defined as prior to any GLP-1 or GLP-1/GIP agonist), evidence of prior behavioral therapy/dietary restriction (≥3 months), sleep study reports when OSA is claimed (AHI ≥15), and fibrosis staging documentation for MASH/NASH (biopsy ≤3 years or VCTE/MRE/ELF ≤6 months with ELF 9.2–10.5). Examples of acceptable documentation: chart notes, lab results, imaging reports, claims records, prescription receipts, and specialist consultation notes.

Patient identifiers and chart-level documentation.
Baseline BMI prior to any GLP-1 or GLP-1/GIP agonist.
Behavioral modification/diet documentation (≥3 months).
Sleep study report with AHI for OSA claims.
Fibrosis staging: biopsy ≤3 years or VCTE/MRE/ELF ≤6 months (ELF 9.2–10.5).
Specialist consultation notes for MASH/NASH (hepatologist, gastroenterologist, endocrinologist).

Applicable Codes & Mentions

No procedure or billing codes listedmixed

No codes listed

Drug mentions (policy text)mixed

Wegovy injection	semaglutide brand formulation (injection) referenced in coverage criteria
Wegovy tablet	oral semaglutide tablet formulation referenced in coverage criteria
Zepbound	tirzepatide (GLP-1/GIP receptor agonist) referenced in coverage criteria
liraglutide (Saxenda, generic)	GLP-1 agonist referenced as example for baseline definition

No procedure or billing codes listed in this partmixed

No codes listed

Clinical Evidence

≥27Baseline BMI eligible with ≥1 weight‑related comorbidity

≥30Baseline BMI eligible without comorbidity

5%Weight loss threshold for continuation (general agents)

10%Zepbound OSA continuation weight‑loss requirement

7 mo / 8 moInitial approval durations: Wegovy tablet 7 months; Zepbound 8 months

SELECT trial (semaglutide CV outcomes): Semaglutide and cardiovascular outcomes in obesity without diabetes (SELECT) is cited; it assessed Wegovy injection versus placebo for secondary prevention of CV events and demonstrated a statistically significant reduction in MACE.

SURMOUNT-OSA (tirzepatide OSA): The SURMOUNT-OSA trials of tirzepatide for treatment of obstructive sleep apnea and obesity are cited; these were 52-week Phase III randomized trials showing superiority of Zepbound versus placebo on AHI and sleep-apnea outcomes.

These trials are referenced in the policy rationale and evidence sections supporting the MACE and OSA indications respectively.

Definitions & Background

Baseline: Values recorded prior to initiation of any GLP-1 agonist or GLP-1/GIP agonist (policy notes that baseline refers to prior to agents such as liraglutide [Saxenda/generic], Wegovy, or Zepbound).

Moderate OSA: Defined by an apnea-hypopnea index (AHI) ≥ 15 events per hour (policy notes that moderate OSA is AHI ≥15 and severe OSA AHI ≥30).

Wegovy tablet/injection: Policy explicitly references both Wegovy tablet and Wegovy injection for coverage criteria and notes; baseline definitions and approval routing are aligned across both formulations.

Revision History

added

Zepbound was added to the policy with new criteria (initial approval 8 months, continuation 1 year).

revised

Baseline BMI definitions were changed to require baseline (prior to any GLP-1 or GLP-1/GIP agonist) rather than current BMI in several criteria across agents.

revised

Continuation and dosing-related criteria for Wegovy and Zepbound were removed or simplified; approval durations standardized to 1 year for patients currently receiving therapy.

Policy Summary

PayerCigna

PolicySaxenda, Wegovy, Zepbound (GLP-1 / GLP-1/GIP agents) coverage criteria

Policy CodePolicy N/A

Change TypeMultiple additions and revisions (material)

Effective Date

Next Review Date

Key ActionSubmit prior authorization with required documentation (baseline BMI, behavioral therapy, sleep study, fibrosis staging) for Saxenda, Wegovy (tablet and injection), or Zepbound.

On This Page

History of symptomatic peripheral arterial disease (one of)

Intermittent claudication with ankle-brachial index < 0.85ABI < 0.85
Peripheral arterial revascularization procedure
Amputation due to atherosclerotic disease

According to the prescriber, medication will be used in combination with optimized pharmacotherapy for established cardiovascular disease

Medication will be used concomitantly with behavioral modification and a reduced-calorie diet

Agent-specific approval durations and routing: Zepbound initial approval is 8 months with continuation for 1 year; Wegovy (both tablet and injection) initial approvals are 7 months with continuation for 1 year; Saxenda initial/continuation durations are specified in its section. These durations are specified in each agent's FDA-Approved Indications.

Prescriber attestation and optimized pharmacotherapy: For Wegovy MACE risk-reduction coverage, the prescriber must state the medication will be used in combination with optimized pharmacotherapy for established cardiovascular disease, and behavioral modification with a reduced-calorie diet is required across indications.

Wegovy formulations: The policy explicitly references both Wegovy tablet and Wegovy injection across the criteria and notes; both formulations are treated in the agent-specific approval and continuation routing.

Magnetic resonance elastography (MRE) performed within the 6 months preceding treatment with Rezdiffra or Wegovy [documentation required]≤6 months

Enhanced Liver Fibrosis (ELF) test performed within the 6 months preceding treatment with Rezdiffra or Wegovy [documentation required] with a score of ≥ 9.2 to ≤ 10.5 [documentation required]ELF 9.2–10.5; ≤6 months

Because of specialized skills and monitoring, Wegovy for MASH/NASH must be prescribed by or in consultation with a specialist in the condition (e.g., hepatologist)

Documentation specific to MASH/NASH required (chart notes, labs, imaging, claims, prescriptions) including patient identifiers

Documentation Required

Documentation for MASH/NASH and general coverage

Documentation must include patient-specific identifying information (e.g., name, DOB, medical record or plan identifier). For MASH/NASH, provide evidence confirming stage F2 or F3 fibrosis by one of the accepted methods within the specified timeframe: liver biopsy within 3 years, VCTE within 6 months, MRE within 6 months, or ELF test within 6 months with a score between 9.2 and 10.5. For general coverage, include baseline BMI documented prior to initiation of any GLP-1 or GLP-1/GIP agonist and evidence of prior behavioral modification/dietary restriction (≥3 months) where applicable. Wegovy for MASH/NASH must be prescribed by or in consultation with a specialist (e.g., hepatologist); include specialist consultation or prescriber specialty in documentation.

Documentation must include patient identifiers (chart notes, labs, imaging, claims, prescriptions).
Acceptable MASH/NASH tests and timeframes: biopsy ≤ 3 years; VCTE ≤ 6 months; MRE ≤ 6 months; ELF ≤ 6 months (score ≥ 9.2 to ≤ 10.5).
Specialist prescribing or consultation required for Wegovy in MASH/NASH (e.g., hepatologist).
Document baseline BMI measured prior to any GLP-1 or GLP-1/GIP agonist and prior behavioral therapy (≥3 months) when required.

Exclusions (must NOT meet either)

Central sleep apnea
Cheyne Stokes respiration

Medication will be used concomitantly with behavioral modification and a reduced-calorie diet

B) Patient is Currently Receiving Zepbound

Patient is ≥ 18 years of age
At baseline, patient had a BMI ≥ 30 kg/m2≥30 kg/m2
This refers to baseline prior to any GLP-1 or GLP-1/GIP agonist.
Patient has completed ≥ 1 year of therapy with Zepbound≥1 year
Patient has lost ≥ 10% of baseline body weight≥10%
This refers to baseline prior to any GLP-1 or GLP-1/GIP agonist.
According to the prescriber, patient has stability in obstructive sleep apnea signs or symptoms
Medication will be used concomitantly with behavioral modification and a reduced-calorie diet

title": "Zepbound - Obstructive Sleep Apnea, Moderate to Severe, in a Patient with Obesity"}

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Baseline BMI definition: The policy defines baseline values as those recorded prior to initiation of any GLP-1 agonist or GLP-1/GIP agonist (e.g., prior to liraglutide [Saxenda/generic], Wegovy, or Zepbound), and applies this baseline definition across agents and indications.

Revised initial therapy duration routing: Wegovy tablet initial approval duration was changed to 7 months; patients with 7 months of Wegovy tablet therapy who have not completed that initial period should be routed to the Initial Therapy criteria. The policy notes routing patients with less than 7 months of therapy to Initial Therapy criteria.

Provide fibrosis staging evidence for MASH/NASH when relevant.

Documentation Required

Baseline definition requirement / Baseline BMI documentation

Baseline values (including BMI and weight) must be documented as measurements taken prior to initiation of any GLP-1 or GLP-1/GIP agonist. For claims relying on a BMI threshold (e.g., ≥30 kg/m2 or ≥27 kg/m2 plus comorbidity), include documentation showing the baseline BMI date and value. When documenting baseline BMI for continuation or initial eligibility, ensure the baseline predates exposure to agents such as liraglutide (Saxenda), Wegovy, or Zepbound.

Baseline = values recorded prior to initiation of any GLP-1 or GLP-1/GIP agonist.
Document date and numeric BMI value for baseline measurement.
Explicitly note if baseline predates exposure to liraglutide, Wegovy, or Zepbound.

Documentation Required

Documentation for MASH/NASH and general coverage

For MASH/NASH and related coverage, submit patient-identifying documentation plus one of the accepted fibrosis assessments performed within the required timeframe: liver biopsy within 3 years; VCTE within 6 months; MRE within 6 months; or ELF test within 6 months with a score between 9.2 and 10.5. Acceptable documentation formats include chart notes, labs, imaging reports, claims, and prescriptions — all must include patient identifiers.

Liver biopsy ≤ 3 years prior to treatment (report/pathology).
VCTE ≤ 6 months prior to treatment (imaging report).
MRE ≤ 6 months prior to treatment (imaging report).
ELF test ≤ 6 months prior with score ≥ 9.2 to ≤ 10.5 (lab report).
All documentation must include patient-specific identifying information.

Prior Authorization

Initial therapy duration enforcement

Initial approvals for Wegovy tablet are issued for 7 months. Route patients who have not completed 7 months of Wegovy tablet initial therapy to the Initial Therapy criteria. Include expected approval duration and therapy status in the PA to ensure correct routing.

Wegovy tablet initial approval duration = 7 months.
Patients with <7 months of Wegovy tablet therapy should be evaluated per Initial Therapy criteria.

Denial Risk

Claims for concomitant use of GLP-1/GLP-1GIP agents - denial risk

Claims for concomitant use of a GLP-1 agent with another GLP-1 or GLP-1/GIP agonist are considered not medically necessary and may be denied. When reviewing claims, check for overlapping prescriptions of Saxenda, Wegovy (tablet or injection), Zepbound, and other GLP-1/GIP agents; document monotherapy in records to mitigate denial risk.

Concurrent use of GLP-1 and GLP-1/GIP agents is an exclusion and subject to denial.
Examples to watch for: combined prescriptions for Wegovy + Zepbound, Saxenda + Mounjaro, etc.
Ensure records show discontinuation of prior GLP-1/GLP-1GIP before starting another agent.

added

Wegovy indication for Major Adverse Cardiovascular Event(s) risk reduction in patients with established cardiovascular disease was added.

added

Wegovy indication for MASH/NASH was added with fibrosis staging documentation requirements (stage F2/F3 confirmed by biopsy within 3 years or VCTE/MRE/ELF within 6 months) and specialist prescribing/consultation.

clarified

Concomitant use exclusion reworded to specify GLP-1/GIP receptor agonists and to clarify concomitant use with FDA-approved weight-loss medications is not recommended.

administrative

Policy statement added gender-definition note indicating use of biological sex for criteria where asterisked.

revisedLatest

References updated to include both Wegovy injection and Wegovy tablet across multiple criteria and notes.

revised

Continuation criteria clarified to require completion of ≥1 year of Wegovy injection and/or Wegovy tablet and no worsening of fibrosis or MASH/NASH per prescriber.

revised

Initial therapy approval duration for Wegovy tablet changed from 6 months to 7 months; notes route patients with <7 months of therapy to Initial Therapy criteria.

revised

Baseline BMI requirement for OSA in obesity changed from 'current BMI ≥30' to 'at baseline, BMI ≥30', and baseline explicitly defined as prior to any GLP-1 or GLP-1/GIP agonist.

revised

Concomitant use of GLP-1 class agents with each other is not recommended; examples and exclusions updated.

added

Wegovy for MASH/NASH requires documentation and specialist prescribing; documentation examples and timeframes specified.

clarified

Baseline definition for patients currently receiving Zepbound broadened to reference baseline prior to any GLP-1 or GLP-1/GIP agonist (instead of prior to Zepbound only).