ModifiedCignaPOLICY: Weight Loss - Glucagon-Like Peptide-1 Agonists Prior Authorization Policy

Weight Loss - Glucagon-Like Peptide-1 Agonists Prior Authorization Policy

This Cigna policy governs prior authorization and coverage criteria for liraglutide (Saxenda/generic), semaglutide (Wegovy injection and tablets), and tirzepatide (Zepbound) when used for weight loss and certain related indications; it applies to health benefit plans administered by Cigna companies.

Policy Summary

PayerCigna

PolicyWeight Loss - Glucagon-Like Peptide-1 Agonists Prior Authorization Policy

Policy CodePolicy POLICY: Weight Loss - Glucagon-Like Peptide-1 Agonists Prior Authorization Policy

Change TypeMaterial updates to targeted agents, approvals, and documentation

Effective Date

Next Review Date

Key ActionObtain prior authorization and document baseline BMI (measured prior to any GLP-1/GLP-1-GIP therapy) plus a ≥3-month behavioral modification trial before initiating therapy.

SourceLink

POLICY UPDATE CHANGES

Zepbound (tirzepatide) was added to the policy with new initial and continuation criteria and approval durations.

Continuation dosing/tolerance requirements for Wegovy, Saxenda, and Zepbound were removed and approval durations standardized to 1 year for continuing therapy.

Baseline BMI language was modified to specify that baseline refers to status prior to any GLP-1 or GLP-1/GIP agonist.

A new FDA-approved indication for Zepbound: obstructive sleep apnea (moderate to severe) in patients with obesity.

Wegovy tablet was added to the policy and criteria were created; Wegovy tablet included in requirements for MASH/NASH fibrosis identification and in continuity/initial therapy provisions.

A new condition of approval was added for Wegovy for Metabolic Dysfunction‑Associated Steatohepatitis (MASH)/NASH, with documentation requirements and specialist prescribing/consultation requirement.

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3 drugsAgents targeted

1 yearContinuation approval

4–8 mosInitial approval range

≥5%/≥4%Required on-therapy weight loss

F2–F3MASH/NASH requirement

Coverage Criteria for GLP‑1 / GLP‑1‑GIP Agents

General coverage and agent targeting

Covered when ALL of the following are met (policy targets specific agents):

policy_target: Request is for liraglutide (Saxenda/generic), Wegovy (injection or tablet), or Zepbound

Policy targets only agents with FDA‑approved weight‑loss indications; other GLP‑1 agents without weight‑loss indication are not targeted.

authorization_required: Prior authorization obtained per policy

Prior authorization is recommended for these agents; approvals provided for specified durations noted in product criteria.

Wegovy_MASH_specialist: Wegovy injection for MASH/NASH must be prescribed by or in consultation with a physician who specializes in the condition being treated

Documentation required as noted in criteria.

Saxenda (liraglutide) - Initial and continuation therapy

Covered when ONE of the following (adult or pediatric pathways) is met

Saxenda covered indications: A) Initial therapy (adults): Approve for 4 months when ALL of: (i) age ≥18; (ii) trial of behavioral modification and dietary restriction ≥3 months; (iii) baseline BMI ≥30 kg/m2 OR baseline BMI ≥27 kg/m2 with ≥1 weight‑related comorbidity (listed in policy); (iv) medication used with behavioral modification and a reduced‑calorie diet. B) Current recipients (adults): Approve for 1 year when ALL of: (i) age ≥18; (ii) meets baseline BMI/comorbidity criteria; (iii) lost ≥4% of baseline body weight; (iv) medication used with behavioral modification and a reduced‑calorie diet. Pediatric pathways: initial therapy for patients ≥12 and <18 with BMI ≥95th percentile for age/sex (approve 4 months); continuation for pediatric current recipients requires ≥1% BMI reduction from baseline and use with behavioral modification and diet.Liraglutide initial 4 months; continuation ≥4% weight loss (adults)

Baseline refers to status prior to any GLP‑1 or GLP‑1/GIP therapy.

Wegovy (semaglutide injection/tablet) - Weight loss, MACE reduction, MASH/NASH

Covered when ONE of the following indication-specific branches is met

Wegovy weight-loss adult/pediatric: A) Initial therapy (adults): Approve for 7 months when ALL of: (i) age ≥18; (ii) trial of behavioral modification and dietary restriction ≥3 months; (iii) baseline BMI ≥30 kg/m2 OR baseline BMI ≥27 kg/m2 with ≥1 weight‑related comorbidity; (iv) medication used with behavioral modification and a reduced‑calorie diet. B) Current recipients (adults): Approve for 1 year when ALL of: (i) age ≥18; (ii) meets baseline BMI/comorbidity criteria; (iii) lost ≥5% of baseline body weight; (iv) medication used with behavioral modification and a reduced‑calorie diet. Pediatric pathways mirror adult criteria for ages ≥12 to <18 with baseline BMI ≥95th percentile and continuation requires ≥1% BMI reduction.Initial 7 months; continuation ≥5% weight loss (adults)

Baseline refers to status prior to any GLP‑1 or GLP‑1/GIP therapy.

Wegovy for MACE risk reduction: Approve for 1 year when ALL of: (A) age ≥18; (B) baseline BMI ≥27 kg/m2; (C) history of prior MI OR prior stroke OR symptomatic peripheral arterial disease (ABI <0.85 or revascularization or amputation); (D) medication used with optimized pharmacotherapy for CVD per prescriber; (E) used with behavioral modification and reduced‑calorie diet.1 year

Wegovy (semaglutide tablet) - Initial and continuation therapy

Covered when meeting the same indication-specific criteria as Wegovy injection (initial therapy duration and continuation thresholds provided)

Wegovy tablet weight-loss and MACE indications: Initial therapy: Approve for 7 months when ALL of: age ≥18; trial of behavioral modification and dietary restriction ≥3 months; baseline BMI ≥30 kg/m2 OR baseline BMI ≥27 kg/m2 with ≥1 weight‑related comorbidity; medication used with behavioral modification and a reduced‑calorie diet. Current recipients: Approve for 1 year when ALL of: age ≥18; meets baseline BMI/comorbidity criteria; lost ≥5% of baseline body weight; medication used with behavioral modification and a reduced‑calorie diet. MACE and MASH/NASH criteria parallel Wegovy injection (including documentation and specialist requirements for MASH/NASH).

Zepbound (tirzepatide) - Initial and continuation therapy

Covered when ONE of the following (initial or current recipient) is met

Zepbound weight-loss: A) Initial therapy: Approve for 8 months when ALL of: (i) age ≥18; (ii) trial of behavioral modification and dietary restriction ≥3 months; (iii) baseline BMI ≥30 kg/m2 OR baseline BMI ≥27 kg/m2 with ≥1 weight‑related comorbidity; (iv) medication used with behavioral modification and a reduced‑calorie diet. B) Current recipients: Approve for 1 year when ALL of: (i) age ≥18; (ii) meets baseline BMI/comorbidity criteria; (iii) lost ≥5% of baseline body weight; (iv) medication used with behavioral modification and a reduced‑calorie diet.Initial 8 months; continuation ≥5% weight loss (adults)

Baseline refers to status prior to any GLP‑1 or GLP‑1/GIP therapy.

Weight Loss in an Adult with Overweight or Obesity — Initial Therapy (Zepbound example)

Approve for 8 months if the patient meets ALL of the following

Initial Therapy criteria: 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) At baseline, patient had a BMI ≥ 30 kg/m2; OR (b) At baseline, patient had a BMI ≥ 27 kg/m2 AND at baseline or currently has ≥1 weight‑related comorbidity (list in policy); AND iv. Medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.

Baseline refers to status prior to any GLP‑1 or GLP‑1/GIP agonist.

Weight Loss in an Adult — Continuation Therapy (Zepbound example)

Approve for 1 year if the patient meets ALL of the following

Continuation Therapy criteria: i. Patient is ≥ 18 years of age; AND ii. Patient meets ONE of the baseline BMI options (baseline BMI ≥30 kg/m2 OR baseline BMI ≥27 kg/m2 with ≥1 weight‑related comorbidity); AND iii. Patient has lost ≥ 5% of baseline body weight; AND iv. Medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.>=5% weight loss from baseline

If patient has not completed 8 months of initial therapy, refer to Initial Therapy.

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

Approve for 1 year if the patient meets ALL of the following

OSA Initial Therapy criteria: i. Patient is ≥ 18 years of age; AND ii. At baseline, patient had a BMI ≥ 30 kg/m2; AND iii. Sleep study documenting moderate to severe OSA with apnea‑hypopnea index (AHI) ≥ 15 events/hour; AND iv. Patient does NOT have central sleep apnea or Cheyne‑Stokes respiration; AND v. Medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.AHI >= 15

Baseline refers to status prior to any GLP‑1 or GLP‑1/GIP agonist.

Obstructive Sleep Apnea — Continuation Therapy (Zepbound)

Approve for 1 year if the patient meets ALL of the following after completing ≥1 year of therapy

OSA Continuation criteria: i. Patient is ≥ 18 years of age; AND ii. At baseline, patient had a BMI ≥ 30 kg/m2; AND iii. Completed ≥1 year of therapy AND patient has lost ≥10% of baseline body weight AND prescriber documents stability in OSA signs or symptoms; AND iv. Medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.>=10% weight loss

Examples of OSA signs/symptoms include snoring, excessive daytime sleepiness, fatigue.

Coverage criteria (updated items)

Coverage requires meeting product‑specific initial or continuation criteria and documentation; baseline measures are defined relative to GLP therapy.

Baseline BMI requirement: For applicable indications, baseline BMI must meet specified thresholds (examples: baseline BMI ≥30 kg/m2 or baseline BMI ≥27 kg/m2 with ≥1 weight‑related comorbidity). Baseline is defined as the BMI prior to initiation of any GLP‑1 or GLP‑1/GIP therapy.see product criteria

Baseline definition was revised to refer to status prior to any GLP‑1 or GLP‑1/GIP agonist.

MASH/NASH initiation documentation: Initiation of Rezdiffra or Wegovy (injection or tablet) for MASH/NASH requires documentation of stage F2 or F3 fibrosis confirmed by ONE of: liver biopsy within 3 years; VCTE within 6 months; MRE within 6 months; OR ELF test within 6 months with score ≥9.2 to ≤10.5. Documentation must be provided and treatment must be prescribed by or in consultation with an appropriate specialist.F2–F3 fibrosis; ELF 9.2–10.5

Liver fibrosis confirmation options and timeframes are specified in policy.

This policy specifically targets liraglutide (Saxenda/generic), semaglutide (Wegovy injection and tablets), and tirzepatide (Zepbound). Other glucagon-like peptide-1 (GLP-1) agonists that do not carry an FDA‑approved indication for chronic weight management are not the focus of this policy and are therefore not addressed in the coverage criteria herein.

For clarity, GLP‑1 agonists that lack an FDA‑approved indication for weight loss are outside the scope of this policy. Requests for agents without an FDA weight‑loss indication should be evaluated under other applicable coverage rules or benefit plan provisions, as they are not targeted by this policy.

The policy excludes concomitant use of a GLP‑1 agonist with another GLP‑1 agonist or with a GLP‑1/GIP agonist; such combinations are considered not medically necessary. Requests for combined GLP‑1/GLP‑1‑GIP therapy will be evaluated as not medically necessary and may be denied.

Concomitant use of a targeted GLP‑1/GLP‑1‑GIP agent with other medications that are FDA‑approved for weight loss is noted as not recommended for approval. Such combinations are specifically flagged in the policy as a condition that is not recommended and may be treated as not medically necessary.

The policy does not address use of GLP‑1 agents that are not among the named products (Saxenda, Wegovy, Zepbound). Use of GLP‑1 drugs outside the set of targeted agents — specifically those without an FDA‑approved chronic weight‑management indication — falls outside the scope of this policy.

Use of Saxenda, Wegovy, or Zepbound for any indication not explicitly covered by the policy (including uses not listed under the FDA‑approved indications in the criteria sections) is considered not medically necessary.

The policy specifies that using targeted GLP‑1/GLP‑1‑GIP agents in combination with other FDA‑approved weight‑loss medications is not recommended for approval and may be considered not medically necessary; providers should not expect approval when these agents are prescribed concomitantly with other weight‑loss drugs.

Coding, Thresholds, and Key Values

References / Prescribing information (no billing codes in this section)mixed

No codes listed

Required percentage weight loss during therapy — Agent-specific continuation thresholds

Wegovy/semaglutide (including tablet) & Zepbound (tirzepatide)Continuation requires ≥5% weight loss from baseline to qualify for ongoing coverage (adult recipients).

Liraglutide (Saxenda) continuationContinuation requires ≥4% weight loss from baseline where specified (adult recipients).

Pediatric continuation (agents with pediatric indication)Pediatric continuation thresholds mirror adult pathways where specified (see individual agent criteria).

BMI thresholds

Primary baseline BMI criterionBaseline BMI ≥ 30 kg/m2 (measured prior to any GLP-1 or GLP-1/GIP therapy).

Alternate baseline BMI + comorbidity

Prior Authorization, Documentation, and Operational Steps

Prior Authorization

Prior Authorization Required — Approval Durations

Prior authorization is recommended for prescription benefit coverage of liraglutide (Saxenda, generic), Wegovy (injection and tablet), and Zepbound. Approvals are time‑limited per indication and therapy status (initial vs continuing). Refer to the clinical criteria for indication‑specific approval durations.

Saxenda (liraglutide): Initial approvals and continuation approvals have specific month/year durations in the clinical criteria.
Wegovy (injection/tablet): Initial and continuing therapy approvals are time‑limited (see criteria); Wegovy for MASH/NASH requires specialist prescribing or consultation and documentation.
Zepbound: Initial approval durations differ from continuation; continuation standardized to 1 year when criteria are met.

Billing Rule

Claims Submission Note — Use Covered Codes

Background and Indications

Liraglutide (Saxenda), semaglutide (Wegovy), and tirzepatide (Zepbound) are indicated as adjuncts to a reduced‑calorie diet and increased physical activity for chronic weight management. The policy recognizes these agents’ FDA‑approved roles for weight loss and, where applicable, additional indications (for example, Wegovy and Zepbound have indication-specific approvals described in the criteria).

Definitions and Threshold Notes

Specified gender (policy context) — Asterisk note

Definition of specified gender (asterisk)An asterisk (*) next to a specified gender in clinical criteria denotes biological sex: males and females are defined by biological traits regardless of gender identity or expression.

Prescribing requirement contextThis specified-gender definition applies where clinical criteria denote sex-specific limits or thresholds.

Policy noteThe policy explicitly defines these terms to ensure clinical criteria are applied by biological sex when indicated.

Specified gender — Policy definition

'Males' and 'Females' definedIn clinical criteria, 'males' and 'females' refer to biological traits regardless of gender identity or expression.

Applicability

Policy Summary

PayerCigna

PolicyWeight Loss - Glucagon-Like Peptide-1 Agonists Prior Authorization Policy

Policy CodePolicy POLICY: Weight Loss - Glucagon-Like Peptide-1 Agonists Prior Authorization Policy

Change TypeMaterial updates to targeted agents, approvals, and documentation

Effective Date

Next Review Date

Key ActionObtain prior authorization and document baseline BMI (measured prior to any GLP-1/GLP-1-GIP therapy) plus a ≥3-month behavioral modification trial before initiating therapy.

SourceLink

On This Page

Wegovy for MASH/NASH initial and continuation: Initial therapy: Approve for 1 year when ALL of: (i) age ≥18; (ii) no cirrhosis (F4); (iii) stage F2 or F3 fibrosis prior to initiating treatment documented by ONE of: liver biopsy within 3 years OR VCTE within 6 months OR MRE within 6 months OR ELF within 6 months with score ≥9.2 to ≤10.5; (iv) metabolic risk factors managed per prescriber; (v) alcohol consumption <20 g/day (females) or <30 g/day (males); (vi) used with diet and exercise therapy; (vii) prescribed by or in consultation with endocrinologist, gastroenterologist, or hepatologist. Continuation: Approve for 1 year when ALL: completed ≥1 year and no worsening of fibrosis or MASH/NASH; no cirrhosis; metabolic risk factors managed; alcohol limits met; continued diet/exercise; prescribed by/with specialist.1 year

Documentation required for fibrosis staging and specialist involvement.

Continuation criteria updates: Continuation criteria no longer require demonstration of tolerating specific maintenance doses for Wegovy or Zepbound; approval durations for continuing therapy standardized (e.g., Zepbound continuation 1 year). Wegovy tablet initial approval duration set to 7 months.duration as specified in product criteria

Dose‑tolerance requirements for continuation were removed per policy history.

Baseline BMI ≥ 27 kg/m2 PLUS at least one listed weight-related comorbidity (e.g., hypertension, type 2 diabetes, dyslipidemia, OSA, cardiovascular disease, etc.).

Pediatric baselineFor pediatric patients (age ≥12 to <18), baseline defined as BMI ≥ 95th percentile for age and sex (prior to any GLP-1/GLP-1‑GIP therapy).

BMI and weight-loss thresholds — Baseline and continuation (agent-specific)

Baseline BMI options (all weight-loss indications)At baseline (prior to any GLP-1/GLP-1‑GIP therapy): BMI ≥30 kg/m2 OR BMI ≥27 kg/m2 with ≥1 weight-related comorbidity.

Continuation — weight-loss agents (Wegovy, Zepbound)Adult continuation requires ≥5% weight loss from baseline for coverage renewal (1-year approvals when met).

Continuation — liraglutide (Saxenda)Where specified, continuation requires ≥4% weight loss from baseline for ongoing coverage (agent-specific).

Apnea‑Hypopnea Index

Apnea-Hypopnea Index (AHI) thresholdAHI ≥ 15 events per hour defines moderate-to-severe obstructive sleep apnea for coverage of OSA indication.

Severe OSA noteSevere OSA is defined as AHI ≥ 30 events per hour (contextual definition in policy).

Documentation requiredSleep study demonstrating diagnosis and AHI ≥15 events/hour must be provided for OSA indication.

ELF test score — Acceptable range to confirm fibrosis

ELF test acceptable rangeELF test performed within 6 months with a score ≥ 9.2 to ≤ 10.5 to document F2–F3 fibrosis for MASH/NASH initiation.

Alternative fibrosis documentationF2–F3 fibrosis may alternatively be documented by liver biopsy within 3 years, VCTE within 6 months, or MRE within 6 months.

Documentation requirementRequired documentation for fibrosis staging must be included when initiating Wegovy/Rezdiffra for MASH/NASH.

BMI thresholds (alternate references) — Baseline BMI definitions for specific indications

Alternate BMI threshold referencedSome indications (e.g., MACE risk reduction) use baseline BMI ≥ 27 kg/m2 as the eligibility threshold (baseline prior to any GLP-1/GLP-1‑GIP therapy).

OSA baseline BMI definitionFor OSA initial therapy, baseline BMI must be ≥ 30 kg/m2 (measured prior to any GLP-1/GLP-1‑GIP therapy).

Note on 'baseline'Baseline BMI refers to BMI prior to initiation of any GLP-1 or GLP-1/GIP agonist rather than prior to a specific product in current criteria updates.

Claims submitted without covered diagnosis or procedure codes under the applicable coverage policy will be denied as not covered. When billing, providers must use the most appropriate codes as of the submission date.

Claims for services not accompanied by covered code(s) under this policy will be denied.
Ensure diagnosis/procedure codes match the approved indication (e.g., obesity/overweight, OSA, MASH/NASH) and documentation on file.

Denial Risk

Documentation-Related Denials for Wegovy in MASH/NASH

Documentation is required for use of Wegovy injection for MASH/NASH. Lack of required documentation or failure to meet specified timeframes may lead to denial of the request.

Documentation may include chart notes, laboratory results, medical test results, claims records, prescription receipts, and other patient‑specific records.
All documentation must include patient identifiers and be timely per the criteria (e.g., biopsy within 3 years, VCTE/MRE/ELF within 6 months where specified).
Failure to provide required MASH/NASH documentation will result in denial or delay of authorization.

Denial Risk

Concomitant GLP-1/GLP-1-GIP Combination Exclusion

Concomitant use of a GLP‑1 agonist with another GLP‑1 or a GLP‑1/GIP agonist is considered not medically necessary and is not approved.

Examples: Do not combine Saxenda/Victoza, Wegovy, Ozempic, Rybelsus, Trulicity, or Mounjaro with each other.
Requests for overlapping or simultaneous GLP‑1/GLP‑1‑GIP therapies will be denied.

Denial Risk

Concomitant Weight‑Loss Medications — Not Recommended

Concomitant use of GLP‑1/GLP‑1‑GIP agents with other FDA‑approved weight‑loss medications is not recommended and may be denied.

Examples of FDA‑approved weight‑loss medications include, but are not limited to, orlistat, phentermine/topiramate, bupropion/naltrexone, and others as appropriate per labeling.
Document rationale if considering nonstandard combinations; anticipate peer‑to‑peer review and potential denial.

Documentation Required

Documentation Requirement for Wegovy in MASH/NASH

Wegovy for MASH/NASH requires specific supporting documentation at initiation and for continuing therapy. Provide objective evidence of diagnosis, fibrosis staging, and metabolic risk factor management.

Acceptable documentation: liver biopsy within 3 years showing NAFLD activity score ≥4 with required component scores; OR VCTE within 6 months; OR MRE within 6 months; OR ELF within 6 months with score ≥9.2 to ≤10.5.
Documentation must include chart notes, labs, imaging reports, and specialist consultation records as applicable.
Prescriber must be or consult with an endocrinologist, gastroenterologist, or hepatologist for Wegovy in MASH/NASH.

Documentation Required

Required Documentation (General and MASH/NASH‑Specific)

General required documentation for requests includes patient identifiers, baseline BMI (prior to any GLP‑1 or GLP‑1/GIP therapy), record of behavioral modification trial, prior therapy history, and serial weights for percent weight‑loss calculations.

Baseline BMI must be measured prior to initiating any GLP‑1 or GLP‑1/GIP therapy and clearly documented.
Provide documentation of a behavioral modification and reduced‑calorie diet trial of at least 3 months prior to initiation.
Include prior medication history (previous GLP‑1/GIP use, other weight‑loss drugs) and dates of therapy.

Documentation Required

Weight/BMI and Behavioral Modification Documentation

Document baseline weight/BMI and the 3‑month behavioral modification trial used to meet initial‑therapy requirements; include baseline and comparator weights to calculate percent weight loss for continuation decisions.

Baseline weight/BMI refers to the measurement prior to any GLP‑1 or GLP‑1/GIP therapy.
Provide dates and brief description of behavioral program or diet interventions and provider notes confirming participation for ≥ 3 months.
For continuation, document percent weight loss from baseline using weight measurements consistent with the policy definitions.

Documentation Required

OSA Supporting Documentation

For obstructive sleep apnea (OSA) indications, include sleep study results demonstrating diagnosis and severity; an apnea‑hypopnea index (AHI) ≥ 15 is required for moderate‑to‑severe OSA.

Provide sleep study report with diagnosis and AHI value.
Exclude patients with central sleep apnea or Cheyne‑Stokes respiration per policy exclusion criteria.

Documentation Required

Weight Management Supporting Documentation

For weight‑management indications, provide patient age, baseline BMI (prior to any GLP‑1 or GLP‑1/GIP therapy), documentation of behavioral modification trial, and weights used to determine percent change from baseline.

Baseline BMI must be explicit and dated prior to initiation of any GLP‑1/GLP‑1‑GIP therapy.
Document that medication will be used with behavioral modification and a reduced‑calorie diet.
For patients currently receiving therapy, provide evidence of response (e.g., ≥5% or ≥10% weight loss thresholds as required by the indication).

Documentation Required

Fibrosis Confirmation for MASH/NASH

Confirm fibrosis stage F2 or F3 for MASH/NASH when required by providing one of the accepted modalities within the specified timeframe: liver biopsy within 3 years, VCTE within 6 months, MRE within 6 months, or ELF within 6 months with score between 9.2 and 10.5.

Liver biopsy: report with staging showing F2 or F3 and NAFLD activity score details where applicable.
VCTE/MRE reports: performed within 6 months and interpreted consistent with F2–F3 fibrosis range.
ELF test: performed within 6 months with numeric score ≥9.2 and ≤10.5.

Note

Dosing and Switching Considerations

Refer to product‑specific dosing and switching guidance when documenting therapy plans and prior tolerance. Dose escalation schedules, maintenance doses, and switching intervals differ by product and must be followed per prescribing information.

Wegovy injection: 16‑week escalation to 2.4 mg weekly; Wegovy tablet: 90‑day escalation to 25 mg QD with guidance on switching between tablet and injection (timing after discontinuation).
Liraglutide (Saxenda): 4‑week escalation to 3 mg daily with evaluation of weight response at 16 weeks (adults) or 12 weeks (pediatrics) and discontinuation criteria if response thresholds not met.
Zepbound: initiation at 2.5 mg weekly with stepwise increases to maintenance doses (5, 10, 15 mg QW); OSA maintenance doses typically 10 or 15 mg QW.
None of the GLP‑1 or GLP‑1/GIP agonists are recommended for coadministration with another GLP‑1 or GLP‑1/GIP agonist.

Step Therapy

Behavioral Modification Trial Required Before Initiation

Prior to initiating therapy, a trial of behavioral modification and dietary restriction for at least 3 months is required and must be documented. The medication must be used concomitantly with behavioral modification and a reduced‑calorie diet.

Document dates, nature of intervention, and provider confirmation of participation/compliance for the ≥3 month trial.
For indications requiring ongoing behavioral therapy, include plan for continued behavioral modification while on medication.

Documentation Required

Baseline and Prior Therapy Considerations

Measure and document baseline BMI and prior therapy history before any GLP‑1 or GLP‑1/GIP therapy is initiated. Baseline refers to measurements taken prior to starting any GLP‑1/GLP‑1‑GIP agent.

Record prior use of GLP‑1 or GLP‑1/GIP agents, dates of therapy, reasons for discontinuation, and response.
Baseline BMI and weight must be clearly dated and used for all baseline‑to‑on‑therapy comparisons.

This definition is used throughout the policy wherever a specified gender is required for criteria.

Documentation implicationWhen criteria specify gender, the biological definition is applied for eligibility determinations.

Baseline — Definition

Baseline definitionBaseline refers to the patient's status prior to initiation of any GLP‑1 agonist or GLP‑1/GIP receptor agonist.

Use in weight calculationsBaseline weight/BMI is the comparator used to determine percent weight loss for continuation criteria.

Applies across agentsThis baseline definition is applied consistently for liraglutide, semaglutide (Wegovy), and tirzepatide (Zepbound) criteria.

Apnea‑Hypopnea Index (AHI) — Definition and policy threshold

AHI definitionAHI is the number of apneas and hypopneas per hour of sleep; used to define OSA severity in policy criteria.

Policy threshold for moderate-to-severe OSAAHI ≥ 15 events per hour meets the policy threshold for moderate-to-severe obstructive sleep apnea coverage; severe OSA is AHI ≥ 30 events/hour.

Documentation requirementA sleep study showing diagnosis and the AHI (≥15) is required for OSA indication eligibility.

Specified gender in criteria — Asterisk notation

Asterisk meaning in criteriaAn asterisk next to a specified gender indicates the specified term refers to biological sex (males/females defined by biological traits).

RationaleThe policy adds this notation to clarify interpretation of sex-specific clinical criteria such as alcohol limits or fibrosis staging where sex matters.

Applies throughout documentThis notation is applied in clinical criteria as appropriate to ensure consistent application of sex-specific rules.

Baseline BMI — Definition

Baseline BMI defined relative to prior GLP therapyBaseline BMI is defined as the BMI prior to any GLP‑1 agonist (e.g., liraglutide, Wegovy) or GLP‑1/GIP agonist (e.g., Zepbound).

PurposeThis baseline measure is used to determine eligibility and percent weight‑loss calculations for continuation across agents.

Documentation implicationProviders must document baseline BMI measured before initiating any GLP‑1/GLP‑1‑GIP therapy when submitting prior authorization requests.