Weight Loss — GLP‑1 and GLP‑1/GIP Agonists (Saxenda, Wegovy, Zepbound) Coverage Criteria
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Cigna policy defining medical necessity and benefit-exclusion override criteria to authorize coverage of liraglutide (Saxenda), semaglutide (Wegovy), and tirzepatide (Zepbound) for weight loss and select FDA indications in adults and pediatric patients; affects providers prescribing or requesting prior authorization for these agents under Cigna-administered plans.
Wegovy indication for major adverse cardiovascular event risk reduction in patients with established cardiovascular disease who are overweight or obese was added.
List of qualifying comorbidities for patients with BMI ≥ 27 kg/m2 expanded to include knee osteoarthritis, asthma, COPD, non‑alcoholic fatty liver disease (metabolic‑associated steatotic liver disease), polycystic ovarian syndrome, and coronary artery disease.
Criteria related to tolerating or reaching specific Wegovy maintenance doses were removed and approval duration for continuing Wegovy therapy standardized to 1 year.
Conditions not covered clarified to prohibit concomitant use of GLP‑1 agonists or GLP‑1/GIP agonists together and added concomitant use with other weight loss medications as not medically necessary.
Removal of requirements that patients demonstrate tolerance of specific maintenance doses for saxenda, wegovy, and zepbound when continuing therapy.
Policy authorization for Wegovy to reduce major adverse cardiovascular events in patients with established CVD who are overweight or obese was removed.
Authorization of Wegovy for metabolic dysfunction‑associated steatohepatitis (MASH)/NASH with requirement for documented F2–F3 fibrosis confirmed by biopsy, VCTE, MRE, or ELF score.
Baseline BMI definitions were clarified to reference 'baseline prior to any GLP-1 or GLP-1/GIP receptor agonist' for several indications.
Wegovy tablet and Wegovy injection both explicitly included throughout criteria; initial approval duration for Wegovy tablet changed to 7 months.
Coverage Criteria for GLP-1 / GLP-1-GIP Therapies
Liraglutide (Saxenda) — Initial and Continuing Therapy
Liraglutide is covered when ONE of the following is met (1 or 2):
Liraglutide coverage
Adult Weight Loss - Initial Therapy
- i. Patient is ≥ 18 years of age
- ii. Trial of behavioral modification and dietary restriction for at least 3 months
iii. Baseline BMI criteria (one of)
- a: At baseline patient had a BMI ≥ 32 kg/m2 [documentation required]
- b: At baseline patient had a BMI ≥ 27 kg/m2 [documentation required] AND at baseline had, or currently has, at least TWO qualifying weight‑related comorbidities (hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, cardiovascular disease, knee osteoarthritis, asthma, COPD, metabolic dysfunction‑associated steatotic liver disease/non‑alcoholic fatty liver disease, polycystic ovarian syndrome, or coronary artery disease) [documentation required]
- iv: The medication will be used concomitantly with behavioral modification and a reduced‑calorie diet
- v: Documentation required (baseline refers to baseline prior to any GLP‑1 or GLP‑1/GIP receptor agonist)
Adult Weight Loss - Currently Receiving
- i: Patient is ≥ 18 years of age
ii. Baseline BMI criteria (one of)
- a: At baseline patient had a BMI ≥ 32 kg/m2 [documentation required]
- b: At baseline patient had a BMI ≥ 27 kg/m2 [documentation required] AND at baseline had, or currently has, at least TWO qualifying weight‑related comorbidities [documentation required]
- iii: Patient has lost ≥ 4% of baseline body weight [documentation required]
- iv: Medication used concomitantly with behavioral modification and a reduced‑calorie diet
- note: If patient has not completed 4 months of initial therapy, refer to Initial Therapy criteria
Pediatric Weight Loss - Initial Therapy
- i: Patient is ≥ 12 years and < 18 years of age
- ii: Trial of behavioral modification and dietary restriction for at least 3 months
- iii: At baseline patient had a BMI ≥ 95th percentile for age and sex [documentation required] (baseline prior to any GLP‑1 or GLP‑1/GIP agent)
- iv: Medication used concomitantly with behavioral modification and a reduced‑calorie diet
- v: Documentation required
Pediatric Weight Loss - Currently Receiving
- i: Patient is ≥ 12 years and < 18 years of age
- ii: At baseline patient had a BMI ≥ 95th percentile for age and sex [documentation required] (baseline prior to any GLP‑1 or GLP‑1/GIP agent)
- iii: Patient has had a reduction in BMI of ≥ 1% from baseline [documentation required]
- iv: Medication used concomitantly with behavioral modification and a reduced‑calorie diet
- note: If patient has not completed 4 months of initial therapy, refer to Initial Therapy criteria
Wegovy (semaglutide) — Weight loss, CV risk reduction, MASH/NASH
Wegovy injection is covered when ONE of the following is met (1, 2, 3, or 4):
Wegovy coverage
Adult Weight Loss - Initial Therapy
- i: Patient is ≥ 18 years of age
- ii: Trial of behavioral modification and dietary restriction for at least 3 months
iii. Baseline BMI criteria (one of)
- a: At baseline patient had a BMI ≥ 32 kg/m2 [documentation required]
- b: At baseline patient had a BMI ≥ 27 kg/m2 [documentation required] AND at baseline had, or currently has, at least TWO qualifying weight‑related comorbidities (hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, cardiovascular disease, knee osteoarthritis, asthma, COPD, metabolic dysfunction‑associated steatotic liver disease/non‑alcoholic fatty liver disease, polycystic ovarian syndrome, or coronary artery disease) [documentation required]
- iv: Medication used concomitantly with behavioral modification and a reduced‑calorie diet
- v: Documentation required (baseline refers to prior to any GLP‑1 or GLP‑1/GIP agent)
Adult Weight Loss - Currently Receiving
- i: Patient is ≥ 18 years of age
ii. Baseline BMI criteria (one of)
- a: At baseline patient had a BMI ≥ 32 kg/m2 [documentation required]
- b: At baseline patient had a BMI ≥ 27 kg/m2 [documentation required] AND at baseline had, or currently has, at least TWO qualifying weight‑related comorbidities [documentation required]
- iii: Patient has lost ≥ 5% of baseline body weight [documentation required]
- iv: Medication used concomitantly with behavioral modification and a reduced‑calorie diet
- note: If patient has not completed 7 months of initial therapy, refer to Initial Therapy criteria
Pediatric Weight Loss
- Pediatric Initial: Patient is ≥ 12 and < 18 years; trial of behavioral modification ≥3 months; at baseline BMI ≥ 95th percentile for age/sex [documentation required]; medication used with behavioral modification and diet; documentation required
- Pediatric Continuing: Patient is 12–17 years; at baseline BMI ≥ 95th percentile [documentation required]; patient has had BMI reduction ≥1% from baseline [documentation required]; medication used with behavioral modification and diet; documentation required
CV Risk Reduction
- A: Patient is ≥ 18 years of age
- B: At baseline patient had a BMI ≥ 27 kg/m2 [documentation required] (baseline prior to any GLP‑1 or GLP‑1/GIP agent)
C. Qualifying CVD history (one of)
- i: Prior myocardial infarction
- ii: Prior stroke (does not include TIA)
- iii: History of symptomatic peripheral arterial disease evidenced by one of: intermittent claudication with ABI < 0.85; peripheral arterial revascularization; or amputation due to atherosclerotic disease
- D: Prescriber states medication will be used in combination with optimized pharmacotherapy for established CVD
- E: Medication used concomitantly with behavioral modification and a reduced‑calorie diet
- note: Documentation required for baseline BMI and qualifying CVD history
MASH/NASH
- i: Patient is ≥ 18 years of age
- ii: Patient does not have cirrhosis (F4)
- iii: Patient has stage F2 or F3 fibrosis prior to initiating treatment with Rezdiffra, Wegovy injection, or Wegovy tablet confirmed by ONE of: liver biopsy within the prior 3 years; VCTE within 6 months; MRE within 6 months; or ELF test within 6 months with score ≥ 9.2 to ≤ 10.5 [documentation required]
- iv: One or more managed metabolic risk factors (central obesity, hypertriglyceridemia, low HDL, hypertension, elevated fasting glucose indicative of diabetes/prediabetes) per prescriber
- v: Alcohol consumption limits met (female <20 g/day; male <30 g/day)
- vi: Medication used in combination with appropriate diet and exercise therapy
- vii: Prescribed by or in consultation with an endocrinologist, gastroenterologist, or hepatologist
Wegovy — Major Adverse Cardiovascular Event Risk Reduction
Approve for 1 year when ALL of the following are met
Cardiovascular risk reduction criteria
- A: Patient is ≥ 18 years of age
- B: At baseline, patient had a BMI ≥ 27 kg/m2 [documentation required] (baseline prior to any GLP‑1 or GLP‑1/GIP agent)
C. Qualifying CVD history (one of)
- i: Prior myocardial infarction
- ii: Prior stroke (does not include TIA)
- iii: History of symptomatic peripheral arterial disease evidenced by one of: intermittent claudication with ankle‑brachial index < 0.85; peripheral arterial revascularization procedure; or amputation due to atherosclerotic disease
- D: Prescriber states medication will be used in combination with optimized pharmacotherapy for established CVD
- E: Medication used concomitantly with behavioral modification and a reduced‑calorie diet
This policy authorizes coverage of specified GLP‑1 and GLP‑1/GIP agents for FDA‑approved weight‑loss indications and select non–weight‑loss FDA indications when the documented clinical criteria are met. Although Wegovy is referenced throughout the criteria, the Wegovy tablet formulation is not a targeted product for this policy’s outreach program; where applicable, Wegovy tablet is included in the criteria set and initial approval duration for Wegovy tablet is aligned with the Wegovy injection criteria. Documentation is required for use of liraglutide (Saxenda, generic), Wegovy (injection or tablet), and Zepbound as specified in the criteria (e.g., chart notes, prescription claims, receipts) and must include patient‑specific identifying information.
Use of liraglutide (Saxenda, generic), Wegovy (injection or tablet), and Zepbound for indications or purposes not specifically listed in this coverage policy is considered not medically necessary and is not covered. Providers should request prior authorization only for uses that meet the policy’s clinical criteria and supply required documentation; other uses will be subject to denial as not covered.
Concomitant use of these products with other medications FDA‑approved for weight loss is not recommended. The policy now explicitly clarifies that combining GLP‑1 or GLP‑1/GIP receptor agonists with other FDA‑approved weight‑loss drugs is not recommended and may affect authorization decisions.
Claims for services or dispensing that are billed for conditions or diagnoses not covered under this policy will be denied. Providers must submit claims using the most appropriate covered diagnosis and procedure codes in effect on the date of submission; reimbursement is not allowed when services are billed without covered code(s) under the applicable coverage policy.
Concomitant administration of GLP‑1 agonists with other GLP‑1 agonists or GLP‑1/GIP agonists, or administration together with other weight‑loss medications, is considered not medically necessary. Requests for coverage involving such combination therapy will not meet medical necessity criteria and may be denied.
The policy previously included an authorization pathway for Wegovy to reduce the risk of major adverse cardiovascular events (MACE) in patients with established cardiovascular disease; that indication has been removed and is no longer approved under this policy. Requests for Wegovy for MACE risk reduction will not be authorized per the updated policy.
Coding and Clinical Thresholds
| affected codes | References to covered diagnosis and/or procedure code(s) required when billing; providers must use most appropriate codes as of submission date. |
Provider Actions, Documentation & Prior Authorization
Prior authorization required when clinical criteria met
Prior authorization is required for liraglutide (Saxenda), Wegovy (injection or tablet), and Zepbound and coverage is authorized only when the patient meets the specific clinical criteria and required documentation described in the policy (age, baseline BMI defined as prior to any GLP‑1 or GLP‑1/GIP therapy, behavioral trial, comorbidities, and applicable diagnostic test results).
- Authorization only when clinical criteria and documentation are met (see applicable indication-specific criteria).
Prior authorization — required documentation
When submitting a prior authorization, include documentation of patient age, baseline BMI (defined as BMI prior to any GLP‑1 or GLP‑1/GIP therapy), evidence of a ≥3-month behavioral modification and dietary restriction trial, relevant baseline comorbidities, and any required diagnostic test results referenced for the indication.
- Age and identifying information (chart notes, prescription records, receipts) [documentation required].
- Baseline BMI documented as prior to any GLP‑1 or GLP‑1/GIP agent [documentation required].
- Evidence of ≥3 months behavioral modification and dietary restriction [documentation required].
- Documentation of qualifying comorbidities when BMI ≥27 kg/m2 pathway is used [documentation required].
- Diagnostic test results as applicable (e.g., sleep study AHI, VCTE/MRE/ELF/biopsy for MASH/NASH).
Dose‑tolerance requirement removed for continuing therapy
The policy no longer requires documentation that a patient tolerates specific maintenance doses for Saxenda, Wegovy, or Zepbound when requesting continuation; continuing therapy approvals are standardized to 1 year.
- Removed prior requirement to document tolerance of Saxenda, Wegovy, or Zepbound maintenance doses for continuation.
- Continuing therapy approval duration set to 1 year for Wegovy and Zepbound per policy changes.
Follow prescribing information for dose escalation and coadministration
Follow the product prescribing information for dose‑escalation schedules; if a patient does not tolerate an escalation step, consider delaying escalation per labeling, and do not coadminister GLP‑1 or GLP‑1/GIP agents with each other.
- Wegovy injection escalation reaches 2.4 mg at Week 17; delay escalation 4 weeks if not tolerated.
- Liraglutide escalation per labeling (evaluate weight at 16 weeks for adults); delay escalation ~1 week if not tolerated.
- None of the GLP‑1 or GLP‑1/GIP agonists are recommended for coadministration with other GLP‑1 or GLP‑1/GIP agonists.
Behavioral modification trial required (≥3 months)
Document that the patient completed a trial of behavioral modification and dietary restriction for at least 3 months prior to initiating weight‑loss therapy as required by the initial therapy criteria for adult and pediatric indications.
- Behavioral modification/dietary restriction trial of ≥3 months is required for initial approval pathways (adult and pediatric).
Baseline BMI must be measured prior to any GLP‑1/GLP‑1‑GIP therapy
When determining sequencing or step‑therapy eligibility, use the baseline BMI measured prior to any GLP‑1 or GLP‑1/GIP receptor agonist exposure; baseline timing affects which BMI threshold pathway (≥32 kg/m2 or ≥27 kg/m2 plus comorbidities) applies.
- ‘Baseline’ refers to BMI prior to any GLP‑1 or GLP‑1/GIP receptor agonist (e.g., Saxenda, Wegovy, Zepbound).
- Baseline BMI is used to determine the applicable eligibility pathway and continuation thresholds.
Examples of documentation to include with PA requests
Include examples of supporting documentation with PA requests such as chart notes, prescription claims records, prescription receipts, prior therapy history, and baseline weight/BMI measurements with patient identifiers.
- Chart notes and prescription records showing prior therapies and dates.
- Receipts or pharmacy records documenting prior medication fills.
- Baseline weight/BMI values and dates (prior to any GLP‑1/GLP‑1‑GIP exposure).
Baseline and diagnostic test documentation and time windows
Document baseline BMI (defined as prior to any GLP‑1 or GLP‑1/GIP therapy) and submit required diagnostic tests within specified windows when applicable: liver biopsy ≤3 years, VCTE or MRE ≤6 months, ELF ≤6 months (ELF score 9.2–10.5), sleep study AHI for OSA, or ABI for peripheral arterial disease.
- MASH/NASH fibrosis testing windows: liver biopsy within 3 years; VCTE/MRE/ELF within 6 months (ELF score ≥9.2–≤10.5) [documentation required].
- Sleep study (AHI) for OSA indications (AHI ≥15 for moderate OSA) [documentation required].
- Ankle‑brachial index (ABI) <0.85 for symptomatic peripheral arterial disease documentation when required for CV criteria.
Document percent weight loss and therapy duration for continuation
For continuation approvals, document percent weight loss from the established baseline (e.g., ≥5% for Wegovy and Zepbound continuation; ≥10% for Zepbound OSA continuation) and evidence that titration schedules were completed when required for initial/continuation determinations.
- Wegovy/Zepbound continuation typically requires ≥5% weight loss from baseline [documentation required].
- Zepbound OSA continuation requires ≥10% weight loss and prescriber documentation of symptom stability [documentation required].
- Document completion of titration schedules or maintenance dosing assessments when applicable (per product labeling and prior criteria).
MASH/NASH fibrosis confirmation required (F2–F3) with specified tests/windows
Before initiating Rezdiffra or Wegovy for MASH/NASH, provide documentation confirming stage F2–F3 fibrosis using one of the accepted methods within the specified time windows: liver biopsy within 3 years, VCTE within 6 months, MRE within 6 months, or ELF within 6 months with a score between ≥9.2 and ≤10.5.
- Acceptable tests: liver biopsy (≤3 years), VCTE (≤6 months), MRE (≤6 months), or ELF (≤6 months) with ELF score ≥9.2–≤10.5.
- Documentation that the patient does not have cirrhosis (F4) is required.
Billing/coding mismatch will trigger denial
Claims submitted with diagnoses or procedure codes that are not covered under this policy, or without the appropriate covered code(s), will be denied as not covered; ensure billing codes match the authorized indication and documentation.
- Use the most appropriate codes as of the submission date; mismatched or non-covered codes trigger denials.
Concomitant use with other GLP‑1/GLP‑1‑GIP or weight‑loss drugs is excluded
Concomitant use of GLP‑1 agonists with other GLP‑1 or GLP‑1/GIP agonists or with other FDA‑approved weight‑loss medications is considered not medically necessary and may lead to denial of coverage.
- Do not combine GLP‑1 or GLP‑1/GIP agents with each other or with other weight‑loss medications when seeking coverage under this policy.
Wegovy MACE indication removed — requests may be denied
Wegovy is no longer authorized by this policy for reduction of major adverse cardiovascular events (MACE) in patients with established cardiovascular disease; requests for Wegovy for MACE risk reduction may be denied.
- The MACE indication for Wegovy was removed from the policy and is not authorized.
Background and Scope
Liraglutide, semaglutide (Wegovy), and tirzepatide (Zepbound) are agents within the GLP‑1 receptor agonist class; Zepbound additionally has GIP agonist activity. These medications are indicated with diet and exercise for weight reduction in adults with overweight or obesity and for select pediatric patients, and some agents have additional FDA‑approved non‑weight indications addressed in the policy criteria. Prescribers should follow product labeling for dosing and escalation and supply the documentation required by the authorization criteria when requesting coverage.
Definitions and Test Thresholds
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