CurrentCignaPolicy IP0813

Liraglutide

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This policy governs prior authorization and medical-necessity coverage for Saxenda or generic liraglutide subcutaneous injection used with behavioral modification and a reduced-calorie diet for weight loss in adults and pediatric patients. Coverage is subject to the applicable benefit plan, laws, and the criteria in this policy.

Policy Summary

PayerCigna

PolicyLiraglutide

Policy CodePolicy IP0813

Change TypeNew policy

Effective DateSep 1, 2026

Last ReviewJul 9, 2026

Next Review DateNot specified

Key ActionObtain prior authorization for coverage of Saxenda or generic liraglutide.

SourceLink

POLICY UPDATE CHANGES

The document is identified as a new policy.

Prior authorizationCoverage requirement for liraglutide

4 monthsInitial approval duration

1 yearContinuation approval duration

BMI ≥30Adult baseline obesity threshold

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CurrentCignaPolicy IP0813

Liraglutide

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Get alerted when Policy IP0813 changes without checking for updates manually.

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Policy Summary

PayerCigna

PolicyLiraglutide

Policy CodePolicy IP0813

Change TypeNew policy

Effective DateSep 1, 2026

Last ReviewJul 9, 2026

Next Review DateNot specified

Key ActionObtain prior authorization for coverage of Saxenda or generic liraglutide.

SourceLink

POLICY UPDATE CHANGES

The document is identified as a new policy.

Prior authorizationCoverage requirement for liraglutide

4 monthsInitial approval duration

1 yearContinuation approval duration

BMI ≥30Adult baseline obesity threshold

Concomitant-use exclusion

Medical Necessity Coverage Criteria

Pediatric initial therapy

Approve for 4 months when ALL pediatric initial-therapy criteria are met:

ALL of the following

Patient is at least 12 years of age and younger than 18 years of age.
Patient has engaged in behavioral modification and dietary restriction for at least 3 months.
At baseline, before any GLP-1 agonist or GLP-1/GIP receptor agonist therapy, BMI is at least the 95th percentile for age and sex.BMI ≥ 95th percentile for age and sex
Medication will be used concomitantly with behavioral modification and a reduced-calorie diet.
Preferred product criteria are met for the requested product.

Pediatric continuation therapy

Approve for 1 year when ALL pediatric continuation-therapy criteria are met:

ALL of the following

Patient is at least 12 years of age and younger than 18 years of age.
At baseline, before any GLP-1 agonist or GLP-1/GIP receptor agonist therapy, BMI is at least the 95th percentile for age and sex.BMI ≥ 95th percentile for age and sex
Patient has had a reduction in BMI of at least 1% from baseline.BMI reduction ≥ 1% from baseline
Medication will be used concomitantly with behavioral modification and a reduced-calorie diet.

Concomitant use of liraglutide with another glucagon-like peptide-1 (GLP-1) receptor agonist or with a GLP-1/glucose-dependent insulinotropic polypeptide (GIP) receptor agonist is excluded from coverage.

Coverage does not extend to uses outside the covered adult or pediatric weight-loss indications. Liraglutide (Saxenda or generic) for any other use is considered not medically necessary; the policy notes that the listed examples may not be all-inclusive.

Concomitant use of liraglutide with another GLP-1 receptor agonist or with a GLP-1/GIP agonist is considered not medically necessary.

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

Liraglutide used for purposes outside the specified weight-loss indications is considered not medically necessary.

Saxenda or generic liraglutide used for any purpose other than the policy's covered indications is considered not medically necessary. The policy states that the listed non-covered uses may not be all-inclusive.

Eligibility Thresholds and Response Measures

Adult obesity threshold

Adult obesity thresholdBaseline BMI ≥ 30 kg/m²

Measurement pointBMI is measured before any GLP-1 agonist or GLP-1/GIP receptor agonist therapy

Coverage pathwayQualifies as one of the adult baseline BMI pathways for initial or continuation therapy

Adult overweight threshold

Adult overweight thresholdBaseline BMI ≥ 27 kg/m²

Additional requirementAt least one listed weight-related comorbidity is required

Measurement point

Authorization, Documentation, and Denial Risks

Prior Authorization

Prior Authorization Required

Prior authorization is required for coverage of liraglutide (Saxenda or generic). Approvals are issued for the duration specified in the applicable criteria; when approval is stated in months, 1 month equals 30 days.

Initial therapy approval: 4 months.
Continuation therapy approval: 1 year.

Step Therapy

Generic Liraglutide Required First

For Employer Plans, the patient must first try the bioequivalent generic product, liraglutide subcutaneous injection, before brand Saxenda can be covered.

Generic-first requirement applies to Saxenda (liraglutide subcutaneous).

Clinical Background

Liraglutide is a glucagon-like peptide-1 (GLP-1) receptor agonist used with a reduced-calorie diet and increased physical activity to reduce excess weight and maintain weight reduction.

Policy Definitions

Baseline BMI

Eligibility measurementUse the patient's baseline BMI

Baseline timingMeasure BMI before any GLP-1 agonist or GLP-1/GIP receptor agonist therapy

ApplicationThe baseline BMI applies to adult and pediatric eligibility and continuation criteria

Weight-related comorbidity

Cardiometabolic conditionsHypertension; type 2 diabetes; dyslipidemia; cardiovascular disease; or coronary artery disease

Sleep and musculoskeletal conditionsObstructive sleep apnea or knee osteoarthritis

Respiratory and liver conditions

Policy Summary

PayerCigna

PolicyLiraglutide

Policy CodePolicy IP0813

Change TypeNew policy

Effective DateSep 1, 2026

Last ReviewJul 9, 2026

Next Review DateNot specified

Key ActionObtain prior authorization for coverage of Saxenda or generic liraglutide.

SourceLink

On This Page

BMI and comorbidity status are assessed at baseline before GLP-1 or GLP-1/GIP receptor agonist therapy

Pediatric obesity threshold

Pediatric obesity thresholdBaseline BMI ≥ 95th percentile for age and sex

Eligible age rangePatients are ≥ 12 years of age and < 18 years of age

Measurement pointThe percentile is determined before any GLP-1 agonist or GLP-1/GIP receptor agonist therapy

Adult continuation response

Required responseLoss of ≥ 4% of baseline body weight

Baseline referenceBaseline refers to the measurement before any GLP-1 agonist or GLP-1/GIP receptor agonist therapy

Continuation durationQualifying adult continuation therapy is approved for 1 year

Pediatric continuation response

Required responseReduction in BMI of ≥ 1% from baseline

Baseline referenceBaseline refers to the BMI before any GLP-1 agonist or GLP-1/GIP receptor agonist therapy

Continuation durationQualifying pediatric continuation therapy is approved for 1 year

Adult prescribing-information response assessment

Assessment timingEvaluate body-weight change 16 weeks after initiating liraglutide

Response thresholdThe patient must lose ≥ 4% of baseline body weight

Action for inadequate responseDiscontinue liraglutide if weight loss is <4% of baseline body weight

Pediatric prescribing-information response assessment

Assessment timingEvaluate BMI change after 12 weeks on the maintenance dose

Response thresholdThe patient must have a BMI reduction of ≥ 1% from baseline

Action for inadequate responseDiscontinue liraglutide if BMI reduction is <1% from baseline

Documentation Required

Patient-Specific Documentation Required

Submit patient-specific supporting documentation whenever the criteria identify it as required. Records may include chart notes, laboratory tests, claims records, prescription receipts, and other relevant information.

All documentation must contain patient-specific identifying information.
Documentation may be used to establish baseline BMI or BMI percentile, prior treatment, behavioral and dietary interventions, treatment response, and other applicable criteria.

Documentation Required

Brand Saxenda Exception

A brand Saxenda exception requires documentation that the patient tried the bioequivalent generic liraglutide product and cannot take it because a formulation difference in inactive ingredients would, in the prescriber's judgment, cause a significant allergy or serious adverse reaction.

Document the relevant inactive-ingredient difference, such as dyes, fillers, or preservatives.
Include the prescriber's clinical rationale and patient-specific supporting records.

Denial Risk

Non-Covered Use

Requests may be denied when liraglutide is used outside the policy's specified FDA-approved adult or pediatric weight-loss indications, including other uses not established as medically necessary.

Covered indications are weight loss in adults with overweight or obesity and weight loss in pediatric patients with obesity meeting the policy criteria.
The non-covered-use list is not all inclusive and may be updated as new published data become available.

Denial Risk

Failure to Meet Coverage Criteria

Coverage may be denied when the patient does not meet the applicable initial or continuation criteria for age, baseline BMI or BMI percentile, behavioral and dietary treatment, treatment response, or preferred-product requirements.

Adults: initial therapy requires age ≥ 18, at least 3 months of behavioral modification and dietary restriction, and either baseline BMI ≥ 30 kg/m² or baseline BMI ≥ 27 kg/m² with a qualifying weight-related comorbidity; continuation requires at least 4% loss of baseline body weight.
Pediatric patients: age ≥ 12 and < 18, at least 3 months of behavioral modification and dietary restriction, baseline BMI ≥ 95th percentile for age and sex; continuation requires at least a 1% reduction in BMI from baseline.
Initial and continuation therapy require use with behavioral modification and a reduced-calorie diet; initial therapy also requires the applicable preferred-product criteria.

Denial Risk

Concomitant GLP-1 or GLP-1/GIP Therapy

Liraglutide is not medically necessary when used concomitantly with another GLP-1 receptor agonist or a GLP-1/GIP receptor agonist. Requests involving concurrent therapy may therefore be denied.

Examples include concomitant use with another GLP-1 agonist, Wegovy, or a GLP-1/GIP agonist such as Zepbound.

Asthma; chronic obstructive pulmonary disease; or metabolic dysfunction-associated steatotic liver disease/non-alcoholic fatty liver disease

Other conditionPolycystic ovarian syndrome

Pediatric obesity threshold

Pediatric obesity definitionBMI at or above the 95th percentile for age and sex

Baseline requirementThe percentile is assessed using BMI at baseline

Treatment applicationThe threshold applies to pediatric initial and continuation therapy