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    v1.0.30
    OpenPayerPolicy UpdatesBariatric & Obesity ManagementCigna Foundayo Weight Loss Coverage Update | OpenP…
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    ModifiedCignaPolicy BEO006

    Weight Loss - Glucagon-Like Peptide-1 Agonists - Foundayo Benefit Exclusion Overrides Policy BMI ≥35

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    This policy governs benefit-exclusion overrides and medical-necessity coverage for Foundayo (orforglipron) tablets used with behavioral modification and a reduced-calorie diet for adult weight loss when specified baseline BMI, comorbidity, treatment-duration, and continuation-response criteria are met.

    Policy Summary
    PayerCigna
    PolicyFoundayo Benefit Exclusion Overrides
    Policy CodePolicy BEO006
    Change TypeModified
    Effective DateSeptember 1, 2026
    Last ReviewJul 9, 2026
    Next Review DateN/A
    Key ActionSubmit prior authorization documenting age, baseline BMI, qualifying comorbidities when applicable, lifestyle treatment, and continuation weight response.
    SourceLink
    POLICY UPDATE CHANGES

    Liraglutide, including generic liraglutide to Saxenda, was added to the policy and to applicable adult and pediatric weight-loss criteria.

    Foundayo was added as a product subject to the policy and as an example of a GLP-1 receptor agonist.

    Wegovy tablet and Wegovy HD injection were added to the policy and to criteria previously applying to Wegovy injection.

    Wegovy adult and pediatric weight-loss initial approval duration was changed to 8 months.

    Wegovy tablet weight-loss initial approval duration was changed from 6 months to 7 months, with corresponding continuation language updated.

    Cardiovascular-event risk-reduction criteria were combined for initial and currently receiving therapy, with a 1-year approval duration.

    MASH/NASH criteria now require documented stage F2 or F3 fibrosis before initiating Rezdiffra or Wegovy therapy, confirmed by one of several specified tests.

    Documentation requirements were added for Wegovy treatment of MASH/NASH.

    Saxenda, liraglutide, Wegovy tablet, Wegovy injection, and Zepbound were removed from this policy and moved to new individual policies.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    ≥35 kg/m²Baseline BMI threshold without listed comorbidities
    ≥27 + 2Alternative BMI with qualifying comorbidities
    8 monthsInitial approval duration
    1 yearContinuation approval duration
    ≥5%Required weight loss for continuation

    Medical Necessity and Coverage Criteria

    Initial Therapy

    Covered for the FDA-approved adult weight-loss indication when ALL applicable criteria are met.

    ALL of the following

    • Patient is at least 18 years of age.
    • Patient has engaged in behavioral modification and dietary restriction for at least 3 months.

    • ONE of the following

      • At baseline, before any GLP-1 or GLP-1/GIP agonist therapy, patient had a BMI of at least 35 kg/m².

        Baseline is before any GLP-1 agonist, including liraglutide (Saxenda, generic) or Wegovy, or any GLP-1/GIP receptor agonist, including Zepbound.

      • BOTH of the following

        • At baseline, before any GLP-1 or GLP-1/GIP agonist therapy, patient had a BMI of at least 27 kg/m².
        • At baseline or currently, patient has at least two weight-related comorbidities: hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, cardiovascular disease, knee osteoarthritis, asthma, chronic obstructive pulmonary disease, metabolic dysfunction-associated steatotic liver disease/non-alcoholic fatty liver disease, polycystic ovarian syndrome, or coronary artery disease.
    • Medication will be used concomitantly with behavioral modification and a reduced-calorie diet.

    Continuation Therapy

    For a patient who has not completed the applicable initial-therapy period, refer to Initial Therapy criteria above. Covered for continuation when ALL of the following are met.

    ALL of the following

    • Patient is at least 18 years of age.

    • ONE of the following

      • At baseline, before any GLP-1 or GLP-1/GIP agonist therapy, patient had a BMI of at least 35 kg/m².

        Baseline is before any GLP-1 agonist, including liraglutide (Saxenda, generic) or Wegovy, or any GLP-1/GIP receptor agonist, including Zepbound.

      • BOTH of the following

        • At baseline, before any GLP-1 or GLP-1/GIP agonist therapy, patient had a BMI of at least 27 kg/m².

    Policy Scope and Authorization

    This policy applies to the specified FDA-approved weight-loss products and indications. Prior authorization is recommended for prescription benefit coverage.

    Policy scope and authorization

    • Products targeted by this policy are liraglutide (Saxenda, generic), Wegovy tablet, Wegovy injection, Wegovy HD injection, Zepbound, and Foundayo.
    • Other GLP-1 agonists that do not have an FDA-approved indication for weight loss are not targeted by this policy.
    • Wegovy must be prescribed by, or prescribed in consultation with, a physician who specializes in the condition being treated because of the specialized evaluation, diagnosis, and monitoring required for adverse events and long-term efficacy.
    • Prior authorization is recommended for prescription benefit coverage of liraglutide (Saxenda, generic), Wegovy, and Zepbound.

    MASH/NASH — Initial Therapy

    For initial Wegovy therapy for MASH/NASH, ALL criteria must be met and required patient-specific documentation must be submitted.

    ALL of the following

    • Patient has MASH/NASH with documented stage F2 or F3 fibrosis before initiating treatment with Rezdiffra, Wegovy injection, Wegovy tablet, or Wegovy HD injection.

    • ONE of the following diagnostic methods, with documentation

      • Liver biopsy performed within 3 years before treatment with Rezdiffra or Wegovy demonstrates the qualifying disease and stage F2 or F3 fibrosis.

        Documentation required.

      • Vibration-controlled elastography (VCTE) performed within 6 months before treatment with Rezdiffra or Wegovy documents stage F2 or F3 fibrosis.

        Documentation required.

      • Magnetic resonance elastography (MRE) performed within 6 months before treatment with Rezdiffra or Wegovy documents stage F2 or F3 fibrosis.

    Weight-Loss Approval Duration

    Approval duration depends on the product and whether the request is for initial or continuation therapy.

    Weight-loss approval duration

    • Initial therapy

      • Foundayo: approve for 8 months when the applicable Initial Therapy criteria are met.8 months
      • Wegovy injection or Wegovy HD injection: approve for 8 months when the applicable Initial Therapy criteria are met.8 months
      • Wegovy tablet: approve for 7 months when the applicable Initial Therapy criteria are met.7 months

    • Continuation therapy

    Major Adverse Cardiovascular Event Risk Reduction

    Approve for 1 year for major adverse cardiovascular event risk reduction when ALL applicable criteria are met.

    ALL of the following

    • Patient has established cardiovascular disease.
    • Patient is overweight or obese.
    • At baseline, before any GLP-1 or GLP-1/GIP agonist therapy, patient had a BMI of at least 27 kg/m².BMI ≥ 27 kg/m²

      Baseline is before any GLP-1 agonist, including liraglutide (Saxenda, generic) or Wegovy, or any GLP-1/GIP receptor agonist, including Zepbound.

    • Medication is Wegovy injection, Wegovy tablet, or Wegovy HD injection and is being used for reduction of major adverse cardiovascular events in a patient with established cardiovascular disease.

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

    For Zepbound treatment of moderate-to-severe obstructive sleep apnea in a patient with obesity, ALL criteria must be met.

    ALL of the following

    • Patient has moderate-to-severe obstructive sleep apnea.
    • Patient has obesity with a baseline BMI of at least 30 kg/m².BMI ≥ 30 kg/m²

      Baseline is before any GLP-1 agonist, including liraglutide (Saxenda, generic) or Wegovy, or any GLP-1/GIP receptor agonist, including Zepbound.

    • Zepbound is prescribed for the moderate-to-severe obstructive sleep apnea indication in a patient with obesity.
    • Patient does not have central sleep apnea.

    Concomitant use of Foundayo with another GLP-1 receptor agonist or GLP-1/GIP receptor agonist is not medically necessary because such concomitant use is not recommended.

    Coverage for Zepbound under the moderate-to-severe obstructive sleep apnea indication is not medically necessary when the patient has central sleep apnea. The prior requirement that central apneas or hypopneas comprise at least 50% is not required; the presence of central sleep apnea is the exclusion.

    Foundayo for any use other than the covered adult weight-loss indication is not medically necessary, including uses outside the FDA-approved indication for weight loss.

    Clinical Thresholds and Approval Parameters

    Baseline BMI
    Higher BMI pathwayBaseline BMI ≥35 kg/m²
    Alternative BMI pathwayBaseline BMI ≥27 kg/m²
    Comorbidity requirementAt least two qualifying weight-related comorbidities are required with the BMI ≥27 kg/m² pathway.
    Age
    Minimum age≥18 years
    Eligible populationAdults seeking coverage for weight-loss therapy
    ApplicationThe age requirement applies to initial and continuation therapy.

    Authorization, Documentation, and Denial Risks

    Prior Authorization

    Prior Authorization Documentation Required

    Submit prior authorization with documentation showing the applicable initial-therapy or continuation criteria are met. Use baseline measurements taken before any GLP-1 or GLP-1/GIP agonist when the criteria require baseline BMI or weight.

    • For initial therapy, document age 18 or older, at least 3 months of behavioral modification and dietary restriction, qualifying baseline BMI/comorbidities, and concurrent behavioral modification with a reduced-calorie diet.
    • For continuation therapy, document age 18 or older, qualifying baseline BMI/comorbidities, at least 5% loss of baseline body weight, and continued behavioral modification with a reduced-calorie diet.
    Prior Authorization

    Targeted Products

    Prior authorization is recommended for the targeted products covered by this policy. Other GLP-1 agonists without an FDA-approved indication for weight loss are not targeted under this policy.

    • Targeted products: liraglutide (Saxenda, generic), Wegovy, and Zepbound.

    Policy and Product Background

    Foundayo is an oral GLP-1 receptor agonist indicated for use with a reduced-calorie diet and increased physical activity to reduce excess body weight and maintain long-term weight reduction in adults who have overweight with a weight-related comorbidity or who have obesity.

    Policy Definitions

    Body Mass Index (BMI)
    OverweightBMI ≥25.0 to ≤29.9 kg/m²
    Class I obesityBMI ≥30.0 to ≤34.9 kg/m²
    Class II obesityBMI ≥35.0 to ≤39.9 kg/m²
    Class III obesityBMI ≥40 kg/m²
    Baseline
    DefinitionThe measurement obtained before GLP-1 or GLP-1/GIP agonist therapy.
    GLP-1 examplesLiraglutide and Wegovy
    Policy Summary
    PayerCigna
    PolicyFoundayo Benefit Exclusion Overrides
    Policy CodePolicy BEO006
    Change TypeModified
    Effective DateSeptember 1, 2026
    Last ReviewJul 9, 2026
    Next Review DateN/A
    Key ActionSubmit prior authorization documenting age, baseline BMI, qualifying comorbidities when applicable, lifestyle treatment, and continuation weight response.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaClinical Thresholds and Approval ParametersAuthorization, Documentation, and Denial RisksPolicy and Product BackgroundPolicy Definitions
    At baseline or currently, patient has at least two weight-related comorbidities: hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, cardiovascular disease, knee osteoarthritis, asthma, chronic obstructive pulmonary disease, metabolic dysfunction-associated steatotic liver disease/non-alcoholic fatty liver disease, polycystic ovarian syndrome, or coronary artery disease.
  1. Patient has lost at least 5% of baseline body weight.>= 5%
  2. Medication will be used concomitantly with behavioral modification and a reduced-calorie diet.

    3. Documentation required.

  3. Enhanced Liver Fibrosis (ELF) test performed within 6 months before treatment with Rezdiffra or Wegovy documents stage F2 or F3 fibrosis and has a score from 9.2 through 10.5.9.2–10.5

    Documentation required.

    • Foundayo: approve for 1 year when the applicable continuation criteria are met.1 year
    • For a patient currently receiving Wegovy injection, Wegovy tablet, or Wegovy HD injection, approve continuation for 1 year when the applicable continuation criteria are met.1 year

      If the patient has not completed the applicable initial-therapy period, refer to Initial Therapy criteria above.

    Behavioral and Dietary Treatment Before Initial Therapy
    Required durationAt least 3 months
    Behavioral treatmentBehavioral modification
    Dietary treatmentDietary restriction
    Continuation Weight Response
    Required responseLost ≥5% of baseline body weight
    Measurement referenceResponse is measured against baseline body weight.
    Continuation useThe response requirement applies to continuation therapy.
    Initial Approval Duration
    Approval duration8 months
    Therapy phaseInitial therapy
    Time conventionWhen approval is authorized in months, 1 month equals 30 days.
    Continuation Approval Duration
    Approval duration1 year
    Therapy phaseContinuation therapy
    Incomplete initial therapyPatients who have not completed 8 months of initial therapy are evaluated under initial-therapy criteria.
    MASH/NASH Fibrosis Stage
    Required fibrosis stageF2 or F3 fibrosis
    TimingDocumentation is required before initiating treatment.
    Applicable therapiesThe criterion applies to treatment with Rezdiffra or Wegovy.
    Enhanced Liver Fibrosis Test
    Qualifying ELF range≥9.2 to ≤10.5
    Testing windowELF testing must be performed within 6 months preceding treatment.
    Testing purposeThe ELF test may confirm the required F2 or F3 fibrosis stage.
    Baseline BMI for Cardiovascular-Event Risk Reduction
    Minimum baseline BMI≥27 kg/m²
    Measurement pointBMI is measured at baseline before any GLP-1 agonist therapy.
    Covered contextEstablished cardiovascular disease with overweight or obesity
    Baseline BMI for Zepbound Obstructive Sleep Apnea
    Minimum baseline BMI≥30 kg/m²
    Measurement pointBMI is measured at baseline before any GLP-1 or GLP-1/GIP receptor agonist.
    Covered contextModerate-to-severe obstructive sleep apnea in a patient with obesity
  4. Confirm the product and indication-specific criteria before submitting the request.
    5. Documentation Required

    Wegovy Specialist Involvement

    Wegovy must be prescribed by, or prescribed in consultation with, a physician who specializes in the condition being treated.

    • Document the specialist prescriber or the specialist consultation in the authorization submission.
    Step Therapy

    Preferred Product Requirement

    For initial therapy with Saxenda or generic liraglutide, verify and document that the applicable preferred-product requirement has been satisfied before requesting coverage.

    • Preferred-product requirements were added for Saxenda weight-loss initial therapy in adults and pediatric patients.
    Documentation Required

    Wegovy MASH/NASH Documentation

    For Wegovy treatment of MASH/NASH, submit patient-specific documentation supporting the diagnosis and requested treatment.

    • Acceptable documentation may include chart notes, laboratory results, medical test results, claims records, prescription receipts, and/or other information.
    • All documentation must include patient-specific identifying information.
    Documentation Required

    Fibrosis Testing Requirements

    Before initiating Rezdiffra or Wegovy, document stage F2 or F3 fibrosis using one of the specified methods and the required timing.

    • Liver biopsy performed within 3 years before treatment.
    • Vibration-controlled elastography (VCTE) performed within 6 months before treatment.
    • Magnetic resonance imaging (MRE) performed within 6 months before treatment.
    • Enhanced Liver Fibrosis (ELF) test performed within 6 months before treatment, with a score of ≥ 9.2 to ≤ 10.5.
    Denial Risk

    Eligibility or Response Criteria Not Met

    Coverage may be denied when the patient does not meet the required eligibility or response criteria for the requested indication.

    • Initial therapy: patient must be at least 18 years old, meet the applicable baseline BMI and comorbidity criteria, and have completed at least 3 months of behavioral modification and dietary restriction.
    • Continuation therapy: patient must be at least 18 years old, meet the applicable baseline BMI and comorbidity criteria, and have lost at least 5% of baseline body weight.
    • Use baseline BMI and weight measured before any GLP-1 or GLP-1/GIP agonist when required by the criteria.
    Denial Risk

    Concomitant GLP-1 or GLP-1/GIP Therapy

    Foundayo is not medically necessary when used concomitantly with another GLP-1 receptor agonist or a GLP-1/GIP agonist.

    • Review the medication list for concurrent GLP-1 therapy, including liraglutide, Wegovy, or another GLP-1/GIP agonist such as Zepbound.
    Denial Risk

    Lifestyle Treatment Required

    Document that treatment will be used together with behavioral modification and a reduced-calorie diet. Missing this requirement creates a denial risk for both initial and continuation therapy.

    • Initial therapy requires a trial of behavioral modification and dietary restriction for at least 3 months.
    • Continuation therapy requires ongoing use with behavioral modification and a reduced-calorie diet.
    Denial Risk

    Central Sleep Apnea Exclusion

    Zepbound coverage for moderate-to-severe obstructive sleep apnea in a patient with obesity excludes patients with central sleep apnea.

    • The exclusion applies without the former additional requirement that central apneas/hypopneas comprise at least 50%.
    Denial Risk

    Insufficient Fibrosis Documentation

    Wegovy MASH/NASH coverage may be denied when stage F2 or F3 fibrosis has not been established and documented before treatment initiation.

    • Provide patient-specific documentation from a qualifying liver biopsy, VCTE, MRE, or ELF test within the required timeframe.
    • Do not rely on the prior separate fibrosis criterion or an undated/untimed test; the updated requirement incorporates documented F2 or F3 fibrosis before initiation.
    GLP-1/GIP example
    Zepbound
    Specified Male Gender
    Biological traitsIndividuals with the biological traits of a male
    Gender identityThe definition applies regardless of gender identity.
    Gender expressionThe definition applies regardless of gender expression.
    Specified Female Gender
    Biological traitsIndividuals with the biological traits of a female
    Gender identityThe definition applies regardless of gender identity.
    Gender expressionThe definition applies regardless of gender expression.
    MASH/NASH
    Full termMetabolic dysfunction-associated steatohepatitis
    AbbreviationMASH
    Synonymous terminologyNon-alcoholic steatohepatitis (NASH)