ModifiedCignaPolicy N/A

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

Defines when Cigna will authorize coverage (override a benefit exclusion) for liraglutide (Saxenda), semaglutide (Wegovy injection and tablet), and tirzepatide (Zepbound) for weight loss and selected FDA indications (including MACE risk reduction, MASH/NASH, and OSA), with age, BMI, documentation, and prior‑authorization requirements.

Policy Summary

PayerCigna

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

Policy CodePolicy N/A

Change TypeMaterial — added Wegovy tabletexpanded MACE, Zepbound, and coverage clarifications

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of baseline/current BMI, trial of behavioral modification, required comorbidities, and supporting clinical records as specified for each agent and indication.

SourceLink

POLICY UPDATE CHANGES

A Wegovy indication for reduction of major adverse cardiovascular events in patients with established cardiovascular disease who are overweight or obese was added.

Wegovy tablet was added to the policy with new criteria and baseline BMI notes updated to include Wegovy tablet.

Initial-therapy BMI criterion for Wegovy MACE risk reduction clarified to 'current BMI ≥ 27 kg/m2'.

Zepbound indications expanded to include weight loss in adults with overweight or obesity and obstructive sleep apnea (moderate to severe) with specific approval durations and response criteria.

Conditions Not Covered clarified: concomitant use of GLP-1 agonists or GLP-1/GIP agonists with each other is not recommended; concomitant use with other FDA‑approved weight‑loss medications is not recommended.

≥27Adult BMI threshold (with ≥2 comorbidities)

≥32Adult BMI threshold (without comorbidities)

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≥95th%Pediatric BMI threshold

4 moSaxenda initial approval

7 moWegovy injection initial approval

6 moWegovy tablet initial approval

Coverage Criteria

Coding and Clinical Thresholds

General coding guidancemixed

affected codes

Providers must use the most appropriate codes as of the effective date; claims without covered codes will be denied.

BMI thresholds for coverage — adults and pediatric

Adult — baseline BMI (no comorbidities)Baseline BMI ≥ 32 kg/m2

Adult — baseline BMI with comorbiditiesBaseline BMI ≥ 27 kg/m2 plus ≥2 weight-related comorbidities

Pediatric — age/sex percentileBMI ≥ 95th percentile for age and sex (patients ≥12 and <18 years for Saxenda)

BMI thresholds — baseline and comorbidity-based

Baseline BMI ≥ 32 kg/m2Meets initial therapy criterion when BMI ≥ 32 kg/m2 at baseline (prior to any GLP‑1/GLP‑1‑GIP agent)

Baseline BMI ≥ 27 kg/m2 + comorbiditiesMeets initial therapy criterion when baseline BMI ≥ 27 kg/m2 AND at baseline or currently has ≥2 specified weight‑related comorbidities

Current BMI referencesSome indications (e.g., Wegovy MACE) use current BMI ≥ 27 kg/m2 rather than baseline BMI

On-therapy weight loss thresholds — product-specific continuation

Saxenda (liraglutide) continuationPatient must have lost ≥ 4% of baseline body weight for continuation

Wegovy (semaglutide) injection/tablet continuationPatient must have lost ≥ 5% of baseline body weight for continuation

Pediatric Wegovy continuationPediatric continuation requires a reduction in BMI ≥ 1% from baseline

ELF score range for fibrosis

ELF score rangeELF score ≥ 9.2 to ≤ 10.5

BMI thresholds — current vs baseline and indication‑specific thresholds

Current BMI for MACE indicationCurrent BMI ≥ 27 kg/m2 (Wegovy MACE risk‑reduction initial therapy)

Baseline BMI referencesBaseline BMI refers to BMI prior to initiation of any GLP‑1 or GLP‑1/GIP agent and is used for most initial/continuation criteria (examples: ≥27 kg/m2 or ≥32 kg/m2)

OSA-specific BMI thresholdCurrent or baseline BMI ≥ 30 kg/m2 required for Zepbound OSA criteria

Apnea‑Hypopnea Index thresholds

Moderate OSA cutoff (AHI)Apnea‑Hypopnea Index (AHI) ≥ 15 events per hour

Severe OSA cutoff (AHI)Apnea‑Hypopnea Index (AHI) ≥ 30 events per hour

AHI definitionAHI = number of apneas and hypopneas per hour of sleep

Provider Actions & Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization is required when coverage criteria apply. Approvals are issued for the specific durations noted in the criteria (agent- and indication-specific: e.g., liraglutide/Saxenda initial approvals 4 months; Wegovy examples 6–12 months; Zepbound initial 8 months / current-user approvals 1 year).

Prior authorization must confirm age, baseline BMI, indication, prior therapies, comorbidities, and that behavioral modification/diet will be used concomitantly as required by the indication.
Approval durations are agent- and indication-specific; check the applicable initial vs continuation criteria for the exact approval length.

Denial Risk

Coding-Based Denials

Failure to include appropriate covered diagnosis or procedure codes on claims may result in coding-based denials. Claims submitted without covered codes listed in the applicable coverage policy will be denied as not covered.

Background

GLP‑1 receptor agonists (e.g., liraglutide, semaglutide) and the GLP‑1/GIP agonist (tirzepatide) are indicated for use in conjunction with diet and increased physical activity to achieve and maintain weight loss. The policy requires a documented trial of behavioral modification and dietary restriction (typically ≥3 months) before initial authorization and specifies BMI‑based eligibility thresholds for adults and pediatric patients. Where applicable, individual agents in this class also have additional FDA‑approved indications (for example, some semaglutide products and tirzepatide have cardiovascular or metabolic indications) and approvals under this policy mirror those labeled uses with specified documentation and specialist prescriber requirements.

Definitions

Specified gender — definition

Specified gender — male‘Male’ refers to individuals with the biological traits of a male, irrespective of gender identity or expression

Specified gender — female‘Female’ refers to individuals with the biological traits of a female, irrespective of gender identity or expression

Context of useSpecified gender definition applies where an asterisk (*) is noted next to gender in clinical criteria

Specified gender (restatement)

Biological sex used in criteriaIn clinical criteria, ‘male’ and ‘female’ reference biological traits regardless of gender identity or expression

NotationAn asterisk (*) may appear next to specified gender in criteria to indicate this definition

Policy Summary

PayerCigna

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

Policy CodePolicy N/A

Change TypeMaterial — added Wegovy tabletexpanded MACE, Zepbound, and coverage clarifications

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Verify and submit the most appropriate ICD-10/CPT/HCPCS codes for the requested service and indication.
If the claim lacks a covered diagnosis/procedure code that matches the policy’s allowed uses, expect denial and resubmit with corrected coding.

Denial Risk

Concomitant GLP-1 / GLP-1‑GIP Use Not Allowed

Concomitant use of GLP-1 agonists or GLP-1/GIP receptor agonists with each other (or with other FDA weight‑loss medications) is not medically necessary and is not approved.

Do not combine covered agents (e.g., liraglutide/Saxenda, Wegovy, Zepbound) with other GLP-1 or GLP-1/GIP agents (examples: semaglutide products, tirzepatide, exenatide, dulaglutide, etc.).
Requests for overlapping or combined GLP-1/GLP-1‑GIP therapy will be denied as not covered.

Documentation Required

Baseline & Comorbidity Documentation Required

Document baseline BMI and relevant weight‑related comorbidities at baseline (prior to initiation of any GLP-1 or GLP-1/GIP agent) as required by the criteria. For cardiovascular indications, document prior myocardial infarction, stroke, or evidence of symptomatic peripheral arterial disease when applicable.

Baseline BMI must be recorded and referenced as “baseline prior to any GLP-1 or GLP-1/GIP agent.”
For comorbidity-based eligibility, document at least two qualifying weight‑related comorbidities when required (examples listed in the criteria).
For Major Adverse Cardiovascular Event (MACE) risk-reduction approvals, include documentation of prior MI, prior stroke (excluding TIA), or PAD evidence (ABI <0.85, revascularization, or amputation due to atherosclerotic disease).

Documentation Required

Required Clinical Documentation

Required clinical documentation should be provided with the prior authorization request and may include chart notes, prescription claims records, prescription receipts, lab/study reports, and other supporting records. All documentation must include patient-specific identifiers.

Chart notes demonstrating baseline weight/BMI and the date measured.
Records showing prior behavioral modification/diet trial (timing and duration).
Documentation of qualifying comorbidities or prior cardiovascular events when applicable (e.g., sleep study for OSA criteria, ABI or vascular procedure records for PAD).
Prescription history or claims showing prior GLP-1/GLP-1‑GIP exposure if referenced in the criteria.

Documentation Required

Behavioral Modification Trial Required

A trial of behavioral modification and dietary restriction is required prior to initiation for weight-loss indications. The policy requires at least 3 months of documented behavioral modification/dietary restriction before starting many agents for initial therapy.

Document the behavioral modification program (dates, content, clinician or program name) showing at least 3 months of participation before initiating therapy for initial approvals.
The medication approvals are contingent on concomitant continuation of behavioral modification and a reduced‑calorie diet per the indication.

ApplicabilityDefinition is used where gender‑specific limits or alcohol limits are stated in the criteria

Baseline BMI — definition

DefinitionBaseline BMI = BMI prior to initiation of any GLP‑1 or GLP‑1/GIP agent (e.g., prior to Wegovy injection/tablet or Zepbound)

DocumentationBaseline BMI must be documented when criteria specify ‘baseline’ (used for initiation and some continuation decisions)

Reference usesBaseline BMI thresholds referenced include ≥ 27 kg/m2 and ≥ 32 kg/m2 in multiple initial/continuation criteria

Apnea‑hypopnea index (AHI) — definition and thresholds

DefinitionApnea‑Hypopnea Index (AHI) = number of apneas and hypopneas per hour of sleep

Moderate OSAAHI ≥ 15 events per hour (defines moderate obstructive sleep apnea)

Severe OSAAHI ≥ 30 events per hour (defines severe obstructive sleep apnea)