ModifiedCignaPolicy N/A

Weight Loss - GLP‑1 / GLP‑1‑GIP Benefit Exclusion Overrides Policy

Defines criteria and documentation required for Cigna to authorize coverage (override benefit exclusions) for Saxenda, Wegovy, and Zepbound for weight‑loss and select cardiovascular/OSA indications for covered members.

Policy Summary

PayerCigna

PolicyWeight Loss - GLP‑1 / GLP‑1‑GIP Benefit Exclusion Overrides Policy

Policy CodePolicy N/A

Change TypeClinical coverage and criteria revisions

Effective DateN/A

Next Review DateJan 8, 2025

Key ActionSubmit prior authorization with documentation of age, baseline or current BMI, required behavioral modification trial, relevant comorbidities, and weight‑loss evidence for continuation requests.

SourceLink

POLICY UPDATE CHANGES

Wegovy Major Adverse Cardiovascular Event(s) risk reduction in patients with established cardiovascular disease who are overweight or obese was added as a covered condition.

For continuing therapy with Wegovy and Zepbound, dosing‑related criteria requiring documented tolerance of maintenance doses were removed and approval duration standardized to 1 year.

The list of qualifying weight‑related comorbidities for patients with BMI ≥27 kg/m2 was expanded to include knee osteoarthritis, asthma, COPD, metabolic‑dysfunction associated steatotic liver disease/NAFLD, polycystic ovarian syndrome, and coronary artery disease.

Conditions Not Covered section explicitly lists Saxenda and Wegovy as not covered under certain contexts and states Zepbound is experimental/unproven for other uses; concomitant use with other weight‑loss medications or other GLP‑1/GLP‑1‑GIP agents is prohibited.

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Coverage Criteria for Saxenda, Wegovy, and Zepbound

Saxenda — Weight Loss, Adult

Covered when ALL of the following are met for Initial Therapy (approve 4 months) or Continuing Therapy (approve 1 year):

Saxenda Initial Therapy (Adults): i. Patient is ≥ 18 years of age; AND ii. Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months; AND iii. Patient meets ONE of the following (a or b): a) At baseline, patient had a BMI ≥ 32 kg/m2 [documentation required]; OR b) Patient meets BOTH of the following: (1) At baseline, patient had a BMI ≥ 27 kg/m2 [documentation required]; AND (2) At baseline, patient had, or currently has, at least TWO of the following 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 [documentation required]; AND iv. The medication will be used concomitantly with behavioral modification and a reduced-calorie diet.see BMI thresholds and comorbidity list

Baseline refers to measurements prior to any GLP-1 or GLP-1/GIP agonist.

Saxenda Continuing Therapy (Adults): i. Patient is ≥ 18 years of age; AND ii. Patient meets ONE of the following (a or b): a) At baseline, patient had a BMI ≥ 32 kg/m2 [documentation required]; OR b) Patient meets BOTH of the following: (1) At baseline, patient had a BMI ≥ 27 kg/m2 [documentation required]; AND (2) At baseline, patient had, or currently has, at least TWO of the specified weight-related comorbidities [documentation required]; AND iii. [Patient has lost ≥ 4% of baseline body weight (documentation required)]; AND iv. The medication will be used concomitantly with behavioral modification and a reduced-calorie diet.>=4% weight loss for continuation

For patients who have not completed 4 months of initial therapy, refer to Initial Therapy.

Saxenda — Weight Loss, Pediatric

Covered when ALL of the following are met for Initial Therapy (approve 4 months) or Continuing Therapy (approve 1 year):

Saxenda Pediatric Initial Therapy: i. Patient is ≥ 12 years of age and < 18 years of age; AND ii. Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months; AND iii. At baseline, patient had a BMI ≥ 95th percentile for age and sex [documentation required]; AND iv. The medication will be used concomitantly with behavioral modification and a reduced-calorie diet.BMI ≥95th percentile; see documentation

Baseline refers to measurements prior to any GLP-1 or GLP-1/GIP agonist.

Saxenda Pediatric Continuing Therapy: i. Patient is ≥ 12 years of age and < 18 years of age; AND ii. At baseline, patient had a BMI ≥ 95th percentile for age and sex [documentation required]; AND iii. Patient has had a reduction in BMI of ≥ 1% from baseline [documentation required]; AND iv. The medication will be used concomitantly with behavioral modification and a reduced-calorie diet.>=1% BMI reduction for continuation

For patients who have not completed 4 months of initial therapy, refer to Initial Therapy.

Wegovy — Weight Loss, Adult

Covered when ALL of the following are met for Initial Therapy (approve 7 months) or Continuing Therapy (approve 1 year):

Wegovy Initial Therapy (Adults): i. Patient is ≥ 18 years of age; AND ii. Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months; AND iii. Patient meets ONE of the following (a or b): a) At baseline, patient had a BMI ≥ 32 kg/m2 [documentation required]; OR b) Patient meets BOTH of the following: (1) At baseline, patient had a BMI ≥ 27 kg/m2 [documentation required]; AND (2) At baseline, patient had, or currently has, at least TWO of the following 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 [documentation required]; AND iv. The medication will be used concomitantly with behavioral modification and a reduced-calorie diet.see BMI thresholds and comorbidity list

Baseline refers to measurements prior to any GLP-1 or GLP-1/GIP agonist.

Wegovy Continuing Therapy (Adults): i. Patient is ≥ 18 years of age; AND ii. Patient meets ONE of the following (a or b): a) At baseline, patient had a BMI ≥ 32 kg/m2 [documentation required]; OR b) Patient meets BOTH of the following: (1) At baseline, patient had a BMI ≥ 27 kg/m2 [documentation required]; AND (2) At baseline, patient had, or currently has, at least TWO of the specified weight-related comorbidities [documentation required]; AND iii. Patient has lost ≥ 5% of baseline body weight [documentation required]; AND iv. The medication will be used concomitantly with behavioral modification and a reduced-calorie diet.

Wegovy — Pediatric and MACE indication

Covered when ALL of the following are met for Pediatric or MACE indications:

Wegovy Pediatric: i. Patient is ≥ 12 years of age and < 18 years of age; AND ii. Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months; AND iii. At baseline, patient had a BMI ≥ 95th percentile for age and sex [documentation required]; AND iv. The medication will be used concomitantly with behavioral modification and a reduced-calorie diet; AND v. For continuing therapy, patient has had a reduction in BMI of ≥ 1% from baseline [documentation required].BMI ≥95th percentile; >=1% BMI reduction for continuation

Baseline refers to measurements prior to any GLP-1 or GLP-1/GIP agonist.

Wegovy MACE indication (Adults): i. Patient is ≥ 18 years of age; AND ii. Patient has a current BMI ≥ 27 kg/m2 [documentation required]; AND iii. Patient has had a prior myocardial infarction OR prior stroke OR symptomatic peripheral arterial disease as evidenced by intermittent claudication with ankle-brachial index < 0.85 OR peripheral arterial revascularization OR amputation due to atherosclerotic disease [documentation required]; AND iv. According to the prescriber, the medication will be used in combination with optimized pharmacotherapy for established cardiovascular disease; AND v. The medication will be used concomitantly with behavioral modification and a reduced-calorie diet.current BMI >=27 kg/m2

Zepbound — Coverage header

Zepbound is covered as medically necessary when criteria for FDA‑approved indications or other uses with supportive evidence are met (criteria details follow in subsequent document sections).

Zepbound Coverage Header: Zepbound is addressed in this policy; specific authorization criteria for FDA-approved indications and other supported uses are provided in later sections of the policy.see subsequent policy sections

Documentation is required as noted elsewhere in the policy.

Wegovy — MACE Risk Reduction

Wegovy — Major Adverse Cardiovascular Event(s) (MACE) risk reduction: Approve for 1 year if the patient meets ONE of the following (A or B).

Wegovy MACE indication

A) Initial Therapy: i. Patient is ≥ 18 years of age; AND ii. Patient has a current BMI ≥ 27 kg/m2 [documentation required]; AND iii. Patient meets ONE of the following: prior myocardial infarction [documentation required] OR prior stroke [documentation required] OR symptomatic peripheral arterial disease evidenced by (intermittent claudication with ankle-brachial index < 0.85) OR peripheral arterial revascularization OR amputation due to atherosclerotic disease [documentation required]; AND iv. According to the prescriber, the medication will be used in combination with optimized pharmacotherapy for established cardiovascular disease; AND v. The medication will be used concomitantly with behavioral modification and a reduced-calorie diet.current BMI >=27 kg/m2
Documentation required for BMI and qualifying CV events.
B) Continuing Therapy: i. Patient is ≥ 18 years of age; AND ii. At baseline, patient had a BMI ≥ 27 kg/m2 [documentation required]; AND iii. Patient meets ONE of the qualifying CV event criteria as listed for Initial Therapy [documentation required]; AND iv. According to the prescriber, the medication will be used in combination with optimized pharmacotherapy for established cardiovascular disease; AND v. The medication will be used concomitantly with behavioral modification and a reduced-calorie diet.

Zepbound — Weight Loss (Adult)

Zepbound — Weight Loss, Adult: initial and continuation therapy rules.

Zepbound Weight Loss

A) Initial Therapy: i. Patient is ≥ 18 years of age; AND ii. Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months; AND iii. Patient meets ONE of the following (a or b): a) At baseline, patient had a BMI ≥ 32 kg/m2 [documentation required]; OR b) Patient meets BOTH of the following: (1) At baseline, patient had a BMI ≥ 27 kg/m2 [documentation required]; AND (2) At baseline, patient had, or currently has, at least TWO of the following 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 [documentation required]; AND iv. The medication will be used concomitantly with behavioral modification and a reduced-calorie diet.
Documentation required for BMI and comorbidities; initial approval period 8 months.
B) Continuing Therapy: i. Patient is ≥ 18 years of age; AND ii. Patient meets ONE of the following (a or b): a) At baseline, patient had a BMI ≥ 32 kg/m2 [documentation required]; OR b) Patient meets BOTH of the following: (1) At baseline, patient had a BMI ≥ 27 kg/m2 [documentation required]; AND (2) At baseline, patient had, or currently has, at least TWO of the specified weight-related comorbidities [documentation required]; AND iii. Patient has lost ≥ 5% of baseline body weight [documentation required]; AND iv. The medication will be used concomitantly with behavioral modification and a reduced-calorie diet.

Coverage under this policy is subject to the terms of the applicable benefit plan document and any specific customer plan exclusions. In the event of a conflict between this coverage policy and a member’s benefit plan document, the benefit plan document controls. Coverage determinations require consideration of the plan terms, applicable laws/regulations, relevant collateral materials, and the specific facts of the request; medical directors retain clinical discretion in individual determinations.

The policy explicitly lists products that are included in the "CONDITIONS NOT COVERED" section. Saxenda® (liraglutide) and Wegovy® (semaglutide) are named under "CONDITIONS NOT COVERED." Zepbound® (tirzepatide) is identified as experimental, investigational, or unproven for any other uses not specified in this policy (the policy lists examples including concomitant use with other weight‑loss medications and concomitant use with other GLP‑1 or GLP‑1/GIP agonists).

Concomitant use of GLP‑1 agonists or GLP‑1/GLP‑1‑GIP agonists with each other or with other medications intended for weight loss is not recommended and is considered experimental/investigational/not covered under this policy. The policy specifically states that GLP‑1 agonists and GLP‑1/GIP agonists should not be combined with each other or with any other GLP‑1 or GLP‑1/GIP agonist.

Eligibility Thresholds and Key Clinical Thresholds

inv-11: Adult BMI thresholds — Baseline BMI ≥ 32 kg/m2 OR baseline BMI ≥ 27 kg/m2 plus ≥2 weight-related comorbidities

Adult BMI thresholds (primary)Baseline BMI ≥ 32 kg/m2

Adult BMI thresholds (with comorbidities)Baseline BMI ≥ 27 kg/m2 PLUS at baseline had or currently has ≥2 specified weight‑related comorbidities

Documentation noteBMI must be documented as baseline (prior to any GLP‑1 or GLP‑1/GIP therapy)

inv-12: Pediatric BMI threshold — Baseline BMI ≥ 95th percentile for age and sex (patients ≥12 and <18 years)

Pediatric BMI thresholdBaseline BMI ≥ 95th percentile for age and sex (patients ≥12 and <18 years)

Age requirementPatient is ≥ 12 years and < 18 years

Prior Authorization, Documentation, and Denial Triggers

Prior Authorization

Prior Authorization Required

Prior Authorization Required. Prior authorization is required for Saxenda, Wegovy, and Zepbound. Initial and continuation approval durations vary by drug and indication: Saxenda initial approvals are for 4 months (adults and pediatrics) with continuation approvals for 1 year; Wegovy initial approvals are for 7 months with continuation approvals for 1 year (including cardiovascular risk-reduction indication where initial and continuation durations are specified); Zepbound initial approvals are for 8 months with continuation approvals for 1 year. All approvals are provided for the duration noted in the authorization criteria.

Saxenda: initial therapy approve for 4 months; continuation therapy approve for 1 year.
Wegovy: initial therapy approve for 7 months; continuation therapy approve for 1 year (cardiovascular risk-reduction approvals commonly 1 year).
Zepbound: initial therapy approve for 8 months; continuation therapy approve for 1 year.

Documentation Required

Clinical Background and Scope

Saxenda, Wegovy, and Zepbound are glucagon‑like peptide‑1 (GLP‑1) receptor agonists used as adjuncts to a reduced‑calorie diet and increased physical activity for chronic weight management. Zepbound also has glucose‑dependent insulinotropic polypeptide (GIP) activity in addition to GLP‑1 receptor agonism. These agents are indicated for use in adults and, for certain products, in pediatric patients as specified in the policy.

Definitions and Measurement Thresholds

inv-24: Obesity classes (adult) — Class 1, Class 2, Class 3 definitions by BMI

Class 1 (Adult)BMI ≥ 30 to < 35 kg/m2

Class 2 (Adult)BMI ≥ 35 to < 40 kg/m2

Class 3 (Adult)BMI ≥ 40 kg/m2

inv-25: Pediatric obesity — BMI ≥ 95th percentile for age and sex

Pediatric obesity definitionBMI ≥ 95th percentile for age and sex

Age referenceApplies to pediatric patients ≥ 12 years (per medication indications)

Clinical guidance

Policy Summary

PayerCigna

PolicyWeight Loss - GLP‑1 / GLP‑1‑GIP Benefit Exclusion Overrides Policy

Policy CodePolicy N/A

Change TypeClinical coverage and criteria revisions

Effective DateN/A

Next Review DateJan 8, 2025

SourceLink

On This Page

Documentation is required to support the request. Provide patient age and BMI (baseline and/or current as specified by the criteria), evidence of at least a 3-month trial of behavioral modification and dietary restriction prior to initiating therapy, baseline weight-related comorbidities when applicable, prior cardiovascular events or procedures when relevant (e.g., MI, stroke, PAD with ABI or revascularization, amputation), and objective measures of treatment response for continuation approvals (e.g., ≥4% weight loss for Saxenda continuation; ≥5% weight loss for Zepbound continuation; Wegovy continuation criteria as noted). Acceptable documentation includes chart notes, prescription claims, receipts, and other clinical records.

Denial Risk

Denial Triggers

Denial triggers. Requests lacking required documentation or not meeting the numeric or clinical thresholds in the authorization criteria may be denied. Common denial reasons include missing age or BMI information (or BMI percentile for pediatrics), absence of documentation of a ≥3-month behavioral modification/dietary trial prior to initiation, failure to meet baseline BMI thresholds or comorbidity requirements, and lack of documented treatment response for continuation approvals.

Missing or incomplete documentation of baseline BMI or BMI percentile for pediatric patients.
No documentation of a ≥3-month behavioral modification and dietary restriction trial prior to initial therapy.
Failure to meet BMI thresholds (e.g., adult BMI criteria) or required number/type of weight-related comorbidities.
For continuation: no objective documentation of required percentage weight loss within the specified assessment period.

Note

Dosing and Coadministration

Dosing and Coadministration. Prescribers should follow the labeled dose-titration schedules and consider treatment response and tolerability when selecting maintenance doses. If a patient does not tolerate a dose during escalation, consider delaying escalation per product labeling (e.g., delay ~1 week for Saxenda, consider delaying 4 weeks for Wegovy titration steps). Do not coadminister more than one GLP-1 or GLP-1/GIP agonist; concomitant use of multiple GLP-1 or GLP-1/GIP agents is not recommended and may be considered experimental.

Wegovy: 16-week recommended escalation to maintenance (maintenance 2.4 mg QW or 1.7 mg QW); if intolerant, delay escalation for ~4 weeks and consider lower maintenance or discontinuation per labeling.
Saxenda: 4-week escalation schedule; if intolerant, consider delaying escalation ~1 week; recommended maintenance 3 mg daily for adults and pediatric dosing guidance as labeled; discontinue if unable to tolerate maintenance dose.
Zepbound: start 2.5 mg QW for initiation, increase to 5 mg QW after 4 weeks and then in 2.5 mg increments every ≥4 weeks to maintenance doses of 5, 10, or 15 mg QW (maximum 15 mg QW).

Denial Risk

Concomitant Use Exclusions

Concomitant Use Exclusions. Concomitant use with other medications intended for weight loss is not recommended and is considered experimental/unproven. The GLP-1 agonists and GLP-1/GIP agonists should not be combined with each other; requests for combination therapy with other GLP-1 or GLP-1/GIP agents or with other weight-loss medications may be denied.

Do not combine GLP-1 or GLP-1/GIP agonists with other GLP-1/GLP-1-GIP agents (examples provided in policy).
Concomitant use with other FDA-approved weight-loss medications (e.g., phentermine, Contrave, Qsymia, orlistat) is not recommended and may be considered experimental.
Examples of other GLP-1 agents: Ozempic, Trulicity, Byetta, Bydureon BCise, Rybelsus, Victoza, etc.; example GLP-1/GIP: Mounjaro.