ModifiedCignaPolicy N/A

Weight Loss - GLP-1 / GLP-1-GIP Agonists Benefit Exclusion Overrides

Policy governing coverage authorization (benefit exclusion overrides) for liraglutide (Saxenda/generic), semaglutide (Wegovy), and tirzepatide (Zepbound) for weight loss and select FDA indications for Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyWeight Loss - GLP-1 / GLP-1-GIP Agonists Benefit Exclusion Overrides

Policy CodePolicy N/A

Change TypeMaterial coverage updates (Wegovy MASH/NASH addedbaseline references expandedOSA exclusion simplified)

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization with documentation of baseline BMI, behavioral modification trial (≥3 months), and required diagnostic tests (e.g., biopsy, VCTE/MRE/ELF for MASH/NASH) as specified in criteria.

SourceLink

POLICY UPDATE CHANGES

Wegovy approval criteria expanded to include Metabolic Dysfunction-Associated Steatohepatitis (MASH)/NASH with specific fibrosis staging and diagnostic test windows.

Baseline definition notes updated to explicitly reference liraglutide (Saxenda, generic) and Rezdiffra where applicable.

Obstructive sleep apnea exclusion for central sleep apnea modified by removing requirement that central events comprise ≥50% of events.

Liraglutide (Saxenda, generic) was explicitly added to the policy medication list.

BMI ≥35Adult primary BMI threshold

BMI ≥27 + ≥2 comorbiditiesAlternative adult threshold

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BMI ≥95th %ilePediatric threshold

7 monthsWegovy initial approval

4 monthsSaxenda initial approval

F2–F3MASH/NASH fibrosis required

Coverage Criteria for Saxenda, Wegovy, and Zepbound

Saxenda — Weight loss (adults)

Covered when ONE of the following is met for weight-loss indication in adults

Saxenda adult weight loss: Approve for the duration noted if the patient meets ONE of the following (A or B)

A) Initial Therapy (4 months): Patient is ≥ 18 years; trial of behavioral modification and dietary restriction ≥ 3 months; medication used with behavioral modification and reduced-calorie diet; AND patient meets one of (a) or (b)4 months

a) Baseline BMI: At baseline, patient had BMI ≥ 35 kg/m2 [documentation required]BMI ≥ 35 kg/m2

baseline prior to any GLP-1 or GLP-1/GIP agent

b) BMI 27 + comorbidities: At baseline, patient had BMI ≥ 27 kg/m2 [documentation required] AND at baseline/currently has at least TWO specified weight-related comorbidities (hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, cardiovascular disease, knee osteoarthritis, asthma, COPD, metabolic dysfunction-associated steatotic liver disease/NAFLD, polycystic ovarian syndrome, or coronary artery disease)BMI ≥ 27 kg/m2 + ≥2 comorbidities

documentation required

B) Currently receiving SAXENDA (1 year): Patient is ≥ 18 years and meets baseline BMI criteria as above AND has lost ≥ 4% of baseline body weight [documentation required]; medication used with behavioral modification and reduced-calorie diet≥ 4% weight loss

Approve for 1 year

Saxenda — Weight loss (pediatrics)

Pediatric (≥12 to <18 years) weight-loss coverage

Pediatric initial therapy (4 months): Patient age ≥ 12 and < 18; trial of behavioral modification and dietary restriction ≥ 3 months; baseline BMI ≥ 95th percentile for age and sex [documentation required]; medication used with behavioral modification and reduced-calorie dietBMI ≥ 95th percentile

Approve for 4 months

Pediatric currently receiving (1 year): Patient age ≥ 12 and < 18; baseline BMI ≥ 95th percentile [documentation required]; has reduction in BMI ≥ 1% from baseline [documentation required]; medication used with behavioral modification and reduced-calorie diet≥ 1% BMI reduction

Approve for 1 year

Wegovy — Weight loss and CV risk reduction

Covered when criteria for Wegovy indications are met

Wegovy adult initial therapy (7 months): Patient ≥ 18 years; trial of behavioral modification and dietary restriction ≥ 3 months; medication used with behavioral modification and reduced-calorie diet; AND patient meets one of (a) baseline BMI ≥ 35 OR (b) baseline BMI ≥ 27 with ≥2 weight-related comorbiditiesBMI criteria as above

Approve for 7 months

Wegovy adult continuation (1 year): Patient ≥ 18 years; meets baseline BMI criteria as above; has lost ≥ 5% of baseline body weight [documentation required]; medication used with behavioral modification and reduced-calorie diet≥ 5% weight loss

Approve for 1 year

Wegovy pediatric initial therapy (7 months): Patient ≥ 12 and < 18; trial of behavioral modification and dietary restriction ≥ 3 months; baseline BMI ≥ 95th percentile for age and sex [documentation required]; medication used with behavioral modification and reduced-calorie diet

Some Cigna companies or lines of business provide only utilization review services and do not make coverage determinations for the medications in this policy. In those cases, the terms of the patient’s applicable benefit plan document/control govern whether the medication is a covered benefit and supersede this policy. Documentation requirements described in the policy (for example, baseline BMI, behavioral modification trial, and condition‑specific test results) remain applicable to utilization review activities when requested by the plan.

The concomitant use of two or more GLP‑1 receptor agonists or GLP‑1/GIP agonists is not covered. Examples include combining Saxenda, Wegovy, Zepbound, or other GLP‑1 or GLP‑1/GIP agents together; these agents should not be used in combination and requests for such concomitant therapy will be denied.

Use of Saxenda, Wegovy, or Zepbound for any indication not explicitly listed in the policy’s coverage criteria is considered not medically necessary and is not covered. Requests for indications outside the specified criteria will be denied unless the use matches an approved criterion in this policy or the applicable benefit plan document provides coverage.

Key Coding & Thresholds

BMI / percentile thresholds — Adults and Pediatrics baseline

Adult baseline BMI (primary)BMI ≥ 35 kg/m2 (baseline prior to any GLP-1 or GLP-1/GIP therapy)

Adult alternative BMI + comorbiditiesBMI ≥ 27 kg/m2 at baseline PLUS at least TWO specified weight-related comorbidities (documentation required)

Pediatric baseline BMIPediatric patients (≥12 to <18 years): BMI ≥ 95th percentile for age and sex (baseline prior to any GLP-1 or GLP-1/GIP therapy)

Apnea‑Hypopnea Index (AHI) — severity thresholds

Moderate OSAApnea‑Hypopnea Index (AHI) ≥ 15 events per hour

Severe OSAApnea‑Hypopnea Index (AHI) ≥ 30 events per hour

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Prior authorization is required for covered weight-loss agents (e.g., liraglutide/Saxenda, semaglutide/Wegovy, tirzepatide/Zepbound) and approvals are provided only for the durations specified in the clinical criteria. All requests will be evaluated against the authorization criteria; approvals will be limited to the timeframes noted for initial and continuation therapy.

All requests must include documentation demonstrating member meets age and BMI criteria, behavioral modification trial, and any condition-specific requirements.
Approvals are time-limited (see clinical criteria for 4–8 month initial approval windows and 1-year continuation approvals where specified).

Denial Risk

Coding-related Denial Risk

Claims submitted without covered diagnosis or procedure codes applicable to this policy will be denied as not covered. Use the most appropriate codes as of the date of service; services billed for indications or codes not covered by this policy are subject to denial.

Background and Clinical Context

Liraglutide (Saxenda) and semaglutide (Wegovy) are glucagon‑like peptide‑1 (GLP‑1) receptor agonists indicated, along with diet and increased physical activity, for chronic weight management in adults with overweight or obesity and in selected pediatric patients. Tirzepatide (Zepbound) is a dual GLP‑1 and glucose‑dependent insulinotropic polypeptide (GIP) receptor agonist with similar weight‑loss indications and additional FDA‑approved uses (for example, obstructive sleep apnea in adults with obesity). These agents are prescribed in conjunction with behavioral modification and a reduced‑calorie diet, and approvals under this policy require documentation of baseline BMI and evidence of the required behavioral trial and condition‑specific test results where applicable.

Definitions and BMI Categories

BMI categories — overweight and obesity classes

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

Specified gender (*) — biological sex terminology

Specified gender (*) definitionAn asterisked specified gender indicates biological traits: 'males' = individuals with male biological traits; 'females' = individuals with female biological traits, regardless of gender identity or expression.

Policy Summary

PayerCigna

PolicyWeight Loss - GLP-1 / GLP-1-GIP Agonists Benefit Exclusion Overrides

Policy CodePolicy N/A

Change TypeMaterial coverage updates (Wegovy MASH/NASH addedbaseline references expandedOSA exclusion simplified)

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

BMI ≥ 95th percentile

Approve for 7 months

Wegovy pediatric continuation (1 year): Patient ≥ 12 and < 18; baseline BMI ≥ 95th percentile; reduction in BMI ≥ 1% from baseline [documentation required]; medication used with behavioral modification and reduced-calorie diet≥ 1% BMI reduction

Approve for 1 year

Wegovy CV risk reduction (adults): Patient ≥ 18; current BMI ≥ 27 kg/m2 [documentation required]; established cardiovascular disease (prior MI, prior stroke [not TIA], or symptomatic PAD evidenced by ABI < 0.85, revascularization, or amputation for atherosclerotic disease); medication used with optimized pharmacotherapy for CVD and behavioral modification/dietBMI ≥ 27 kg/m2

Approve for 1 year

AHI definitionAHI = number of apneas and hypopneas per hour of sleep (events/hour)

ELF test score for fibrosis — numeric window

ELF score windowEnhanced Liver Fibrosis (ELF) test score ≥ 9.2 to ≤ 10.5

Timing for ELFELF test must be performed within the 6 months preceding treatment with Rezdiffra or Wegovy (documentation required)

UseELF score used to document stage F2–F3 fibrosis for MASH/NASH eligibility

BMI thresholds — common baseline values

Common adult BMI thresholdsBaseline BMI ≥ 35 kg/m2; OR baseline BMI ≥ 27 kg/m2 with ≥2 specified weight‑related comorbidities

Documentation noteBaseline refers to measurement prior to any GLP‑1 or GLP‑1/GIP therapy (documentation required)

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

Claims lacking covered codes under the applicable benefit plan will be denied.
Verify coding aligns with the authorization criteria and the benefit plan document in effect on the date of service.

Documentation Required

Documentation Required: Clinical documentation must be submitted with prior authorization requests and may include chart notes, prescription claims/records, prescription receipts, lab results, sleep study reports (when applicable), and other relevant clinical records. All documentation must include patient-specific identifying information.

Baseline BMI/weight prior to any GLP-1 or GLP-1/GIP therapy is required and must be documented.
Evidence of a behavioral modification and dietary restriction trial of at least 3 months prior to initial approval.
Documentation of weight-related comorbidities when required (e.g., hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, cardiovascular disease, etc.).
For obstructive sleep apnea, submit sleep study with AHI and diagnostic data.
For MASH/NASH criteria, submit ELF test results when required.

Prior Authorization

Behavioral Modification Requirement

Behavioral Modification Requirement: Members must have engaged in behavioral modification and dietary restriction for at least 3 months prior to initial approval and the medication must be used concomitantly with ongoing behavioral modification and a reduced-calorie diet as specified in the clinical criteria.

Document duration and nature of behavioral/dietary intervention (e.g., program enrollment, counseling notes, weight-management visit notes).
Ongoing use requires continued engagement in behavioral modification and diet therapy as a condition of approval.

Prior Authorization

Behavioral Trial Requirement — Zepbound

Behavioral Trial Requirement for Zepbound: For initial Zepbound authorization, a behavioral modification and dietary restriction trial of at least 3 months is required prior to approval. For patients currently receiving Zepbound, meeting the specified weight-loss thresholds and prior-duration criteria is required for continuation (see clinical criteria for 8-month initial and 1-year continuation rules).

For initial Zepbound requests, document the 3-month behavioral trial and baseline BMI/weight prior to any GLP-1 or GLP-1/GIP therapy.
For continuation in patients already on Zepbound, document prior duration of therapy and required weight-loss thresholds (e.g., ≥5% or ≥10% of baseline where specified).

This definition applies where criteria note a specified gender (e.g., alcohol limits in MASH/NASH criteria)

RationaleUsed to clarify that gendered criteria refer to biological sex rather than gender identity/expression