CurrentCignaPolicy IP0739

Weight Loss - Glucagon-Like Peptide-1 Agonists (Saxenda, Wegovy, Zepbound)

Cigna drug coverage policy (IP0739) for liraglutide (Saxenda, generic), semaglutide (Wegovy injection and tablet), and tirzepatide (Zepbound) addressing authorization criteria for weight loss, cardiovascular risk reduction, MASH/NASH, and OSA indications; includes age, BMI, prior behavioral therapy, documentation, prescriber specialty and duration requirements.

Policy Summary

PayerCigna

PolicyWeight Loss - Glucagon-Like Peptide-1 Agonists (Saxenda, Wegovy, Zepbound)

Policy CodePolicy IP0739

Change TypeCriteria additions and revisions (Wegovy tablet, MASH diagnostic requirements, OSA sleep study timing, contraindication for coadministration)

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization with required documentation (baseline BMI, behavioral therapy history, diagnostic tests for MASH, specialist consult for MASH) to support approvals.

SourceLink

POLICY UPDATE CHANGES

Wegovy tablet criteria added for weight loss in adults with overweight or obesity.

MASH/NASH criteria revised to require documentation of stage F2 or F3 fibrosis confirmed by specific tests and timeframes prior to initiating Rezdiffra or Wegovy.

Wegovy cardiovascular risk reduction criteria clarified that prior stroke does not include TIA.

Zepbound OSA initial therapy sleep study requirement modified to remove the prior 1-year timeframe (still requires a sleep study).

Policy statement updated to authorize coverage for non-weight-loss FDA-approved indications as applicable.

Concomitant use with other GLP-1 or GLP-1/GIP agonists is not recommended / considered not medically necessary.

Wegovy tablet added to policy and criteria for Wegovy injection/tablet cross-referenced for baseline definitions.

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Coverage Summary

Policy stance: covered_with_criteria for liraglutide (Saxenda/generic), semaglutide (Wegovy injection and Wegovy tablet), and tirzepatide (Zepbound) under Cigna Coverage Policy IP0739 effective 2026-03-01.

Major covered indications include: adult and pediatric weight loss (adults: BMI ≥ 35 kg/m2 or ≥ 27 kg/m2 with ≥2 weight-related comorbidities; pediatrics: ≥ 12 to <18 years with BMI ≥ 95th percentile), MACE (major adverse cardiovascular events) risk reduction with Wegovy for adults with established CV disease, MASH/NASH (non-cirrhotic, stage F2–F3 fibrosis) with Wegovy (documentation of fibrosis by biopsy, VCTE, MRE, or ELF required), and obstructive sleep apnea (moderate–severe OSA) with Zepbound.

Scope summary: Cigna drug coverage policy IP0739 addresses authorization criteria (age, baseline BMI, prior behavioral therapy, required documentation and diagnostic tests, prescriber specialty requirements, and specified initial and continuation approval durations) for these products and indications (weight loss, CV risk reduction, MASH/NASH, OSA).

Medically Necessary Criteria (by product and indication)

Medically Necessary - GLP-1 receptor agonists

GLP-1 receptor agonists are considered medically necessary when ONE of the following is met (I, II, III, or IV):

I. Liraglutide (Saxenda, generic)

1. Weight Loss in an Adult with Obesity or Overweight - FDA-Approved Indications
- A) Initial Therapy
  - Patient is ≥ 18 years of age
  - Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months
  - iii. ONE of
    a: At baseline, patient had a BMI ≥ 35 kg/m2
    b: Patient meets BOTH: (1) At baseline, BMI ≥ 27 kg/m2; AND (2) at baseline had or currently has at least TWO 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)
2. Weight Loss in a Pediatric Patient with Obesity
- A) Initial Therapy (approve 4 months)
  - Patient is ≥ 12 years and < 18 years of age
  - Trial of behavioral modification and dietary restriction for at least 3 months
  - At baseline, patient had a BMI ≥ 95th percentile for age and sex
    Note: baseline prior to any GLP-1 or GLP-1/GIP agonist
  - Medication used with behavioral modification and a reduced-calorie diet
  - Preferred product criteria is met
- B) Patient is Currently Receiving liraglutide

Wegovy tablet — Initial and Continuation Criteria

Wegovy tablet - Medically necessary (one of 1 or 2)

Wegovy tablet is considered medically necessary when ONE of the following is met (1 or 2):

1. Weight Loss in an Adult with Overweight or Obesity - Initial Therapy criteria

i: Patient is ≥ 18 years of age
ii: Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months
iii. ONE of
- a: At baseline, patient had a BMI ≥ 35 kg/m2

Wegovy injection — MACE Risk Reduction Criteria

MASH / NASH — Wegovy and Rezdiffra Criteria

Zepbound — Indications and Criteria (Weight Loss, OSA)

Employer Plan — Saxenda (liraglutide) Special Criteria

Employer Plans - Saxenda criteria

Employer Plans - Saxenda criteria: Patient has tried the bioequivalent generic liraglutide subcutaneous injection and cannot take it due to a formulation difference in inactive ingredients which per prescriber would cause significant allergy or serious adverse reaction [documentation required]

[documentation required]

Concomitant Use & Exclusions

Exclusion summary: Concomitant use of GLP-1 agonists or GLP-1/GIP agonists with one another is not recommended and is considered not medically necessary; coadministration of these agents together (e.g., combining Wegovy, Saxenda, Zepbound, or other GLP-1/GIP products) is specifically disallowed.

Clarification: the policy revision explicitly clarified that prior-stroke language excludes transient ischemic attack (TIA is not considered a prior stroke) in the Wegovy MACE criteria.

Provider Actions & Authorization Requirements

Prior Authorization

Authorization required with documentation

Authorization required with documentation. Prior authorization is required for coverage of listed GLP-1 / GLP-1/GIP weight-loss products. Submit supporting documentation at time of request to allow timely review.

Required documentation: chart notes detailing diagnosis and treatment plan
Relevant labs and test results (see MASH/NASH documentation requirements below)
Prior authorization forms, claims history, and prescription receipts or pharmacy records
When applicable for MASH/NASH indications: fibrosis documentation (see specialist and diagnostic requirements)

Documentation Required

Baseline and prior-therapy documentation

Baseline and prior-therapy documentation must be provided for initial and continuation reviews. Include objective baseline measures and a documented history of prior weight-loss interventions.

Applicable Products / Codes

Drugs referencedNDCCovered

liraglutide (Saxenda, generic)	liraglutide subcutaneous injection
semaglutide (Wegovy injection and tablet)	semaglutide injectable and oral
tirzepatide (Zepbound)	tirzepatide subcutaneous injection

Targeted productsNDC|HCPCS|mixed

Wegovy (injection and tablet)	semaglutide products included in policy (brand and formulation distinctions in criteria)
Zepbound	tirzepatide (GLP-1/GIP) product included in policy
Liraglutide (Saxenda, generic)	liraglutide products targeted when FDA-approved for weight loss

Clinical Evidence & Trials

0.80SELECT (Wegovy) MACE HR 0.80; primary endpoint 6.5% vs 8.0%

Part1ESSENCE (Wegovy) interim: significant fibrosis improvement & steatohepatitis resolution (n=800)

-20 / -23.8SURMOUNT-OSA (Zepbound) AHI reductions vs placebo: Trial1 -20.0, Trial2 -23.8 events/hr

Top refsKey trials/guidance: SELECT, ESSENCE, SURMOUNT(-OSA), Wegovy/Saxenda/Zepbound PI, AASLD/AACE guidance (2023-2025)

Evidence narrative: Key trials and outcomes cited in the policy background include SELECT (semaglutide Wegovy) demonstrating MACE reduction (HR 0.80; primary endpoint 6.5% vs 8.0%), ESSENCE (semaglutide in MASH) with significant improvements in fibrosis and steatohepatitis at interim analysis (Part 1, n≈800), SURMOUNT-OSA (Zepbound) showing significant reductions in AHI versus placebo (Trial1 ~-20.0 events/hr; Trial2 ~-23.8 events/hr), and STEP/SURMOUNT series supporting weight-loss efficacy for semaglutide and tirzepatide.

Specialty guidance and context: AASLD practice guidance (2023–2025 updates) and AACE (2025) guidance are cited for MASH staging and weight-management recommendations; the policy notes MASH patient selection and the recommended noninvasive tests (VCTE, MRE, ELF) and thresholds (ELF ≈ 9.2–10.5).

Additional context: Background and prescribing information emphasize dosing escalation schedules and maintenance doses for Wegovy, Wegovy tablet, and Zepbound, and restate that GLP-1/GIP agents should not be coadministered with other GLP-1 or GLP-1/GIP agonists.

Background & Definitions

Background: The policy summarizes product indications and dosing schedules—Wegovy (semaglutide) available as a subcutaneous injection (maintenance 2.4 mg QW) with a 16-week escalation and as an oral tablet (25 mg QD) with a 90-day escalation and cross-switching guidance; liraglutide (Saxenda) has a 4-week escalation and maintenance 3 mg QD with a 16-week weight-loss evaluation; Zepbound (tirzepatide) starts at 2.5 mg QW with stepwise titration to maintenance doses of 5, 10, or 15 mg QW (OSA maintenance 10 or 15 mg QW).

Clinical-context trials highlighted include SELECT for cardiovascular risk reduction with Wegovy, ESSENCE for MASH (showing significant fibrosis and steatohepatitis improvements at interim), and SURMOUNT-OSA for Zepbound (demonstrating large reductions in AHI).

High-level policy notes: Wegovy labeling supports MACE reduction and MASH indications; Zepbound is indicated for moderate–severe OSA in adults with obesity; and the policy reiterates that GLP-1 and GLP-1/GIP agents are not recommended to be coadministered with other agents of the same classes.

Term	Definition
Baseline	Values prior to any GLP-1 or GLP-1/GIP agonist therapy (e.g., liraglutide, Wegovy, Zepbound)
Female/Male	Specified gender refers to biological sex (males = biological male traits; females = biological female traits) regardless of gender identity or expression
Baseline	Refers to measurements prior to any GLP-1 agonist (e.g., liraglutide/Saxenda, Wegovy) or GLP-1/GIP receptor agonist (e.g., Zepbound)
Female/Male (asterisk notation)	Specified gender terms refer to biological traits regardless of the individual's gender identity or gender expression

Revision History

2026-03-01addedLatest

Wegovy tablet criteria added for weight loss in adults with overweight or obesity; initial therapy approval set to 6 months and continuation approval to 1 year with baseline and weight-loss response requirements.

2026-03-01revisedLatest

MASH/NASH criteria revised to require documentation of stage F2 or F3 fibrosis confirmed by liver biopsy within 3 years or VCTE/MRE/ELF within 6 months (ELF score ≥ 9.2 to ≤ 10.5) prior to initiating Rezdiffra or Wegovy; prior broader imaging/lab-based criteria replaced.

Policy Summary

PayerCigna

PolicyWeight Loss - Glucagon-Like Peptide-1 Agonists (Saxenda, Wegovy, Zepbound)

Policy CodePolicy IP0739

Change TypeCriteria additions and revisions (Wegovy tablet, MASH diagnostic requirements, OSA sleep study timing, contraindication for coadministration)

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization with required documentation (baseline BMI, behavioral therapy history, diagnostic tests for MASH, specialist consult for MASH) to support approvals.

SourceLink

On This Page

B) Patient is Currently Receiving liraglutide (Saxenda, generic)

Patient is ≥ 18 years of age
ii. ONE of
- a: At baseline, patient had a BMI ≥ 35 kg/m2
- b: Patient meets BOTH: (1) At baseline, BMI ≥ 27 kg/m2; AND (2) at baseline had or currently has at least TWO weight-related comorbidities (list as above)
Patient has lost ≥ 4% of baseline body weight
Note: baseline prior to any GLP-1 or GLP-1/GIP agonist
The medication will be used concomitantly with behavioral modification and a reduced-calorie diet

Weight Loss - Patient is Currently Receiving Wegovy tablet

i: Patient is ≥ 18 years of age
ii. ONE of
- a: At baseline, patient had a BMI ≥ 35 kg/m2
- b: Patient meets BOTH: (1) At baseline, BMI ≥ 27 kg/m2; AND (2) at baseline had or currently has at least TWO weight-related comorbidities (list as above)
iii: Patient has lost ≥ 5% of baseline body weight
Note: baseline prior to any GLP-1 or GLP-1/GIP agonist
iv: The medication will be used concomitantly with behavioral modification and a reduced-calorie diet

Baseline definition: document baseline weight and BMI immediately prior to treatment initiation; baseline BMI must meet policy thresholds (e.g., BMI ≥ 35 for this policy) and be clearly stated in chart notes
Weight-loss history: detailed prior attempts at weight loss and duration (including behavioral therapy, diet, exercise programs, pharmacotherapy and bariatric surgery history)
Baseline measures: baseline BMI, current BMI, and percent weight loss from baseline when assessing continuation
Behavioral therapy: documentation of ≥ 3 months of supervised lifestyle/behavioral therapy when required by the benefit or policy
Comorbidities: documentation of weight-related comorbid conditions when applicable (e.g., diabetes, OSA, CV disease)
For continuation: percent weight loss from baseline and documentation demonstrating treatment response per product-specific criteria

Prior Authorization

Specialist prescribing requirement for MASH

Specialist prescribing requirement for MASH indications. For MASH (formerly NASH) and related advanced-fibrosis indications, certain products must be prescribed by or in consultation with a specialist.

Wegovy (injection or tablet) and Rezdiffra (resmetirom) for MASH must be prescribed by or in consultation with an endocrinologist, gastroenterologist, or hepatologist
Include documentation of specialist consultation or note from the specialist in the prior authorization submission

Billing Rule

Approval durations and prior authorization recommendation

Approval durations and prior authorization recommendation. Initial approval periods vary by product; consider prior authorization for the listed products and durations below.

Liraglutide (Saxenda): initial approval typically up to 4 months (evaluate weight loss at 16 weeks per PI)
Wegovy injection (semaglutide SC): initial approval typically up to 7 months
Wegovy tablet (semaglutide oral): initial approval typically up to 6 months
Zepbound (tirzepatide): initial approval typically up to 8 months
Continuation approvals: typically up to 1 year when criteria for response are met
State prior authorization (PA) is recommended for the listed products to ensure documentation of baseline and response criteria

Documentation Required

MASH/NASH diagnostic confirmation and baseline notes

Diagnostic confirmation requirements for MASH/NASH and baseline definition notes. Provide objective evidence of liver disease staging and confirmatory testing as specified.

Liver biopsy: histologic confirmation of MASH with staging acceptable if performed within the prior 3 years
Noninvasive testing: acceptable alternatives include vibration-controlled transient elastography (VCTE), magnetic resonance elastography (MRE), or Enhanced Liver Fibrosis (ELF) test performed within the prior 6 months; if ELF used, include the ELF score
Alcohol use: document average alcohol consumption; patients with alcohol consumption exceeding trial limits (≥ 20 g/day for women or ≥ 30 g/day for men) or alcohol dependence may be excluded from MASH indications
Baseline definition note: baseline weight/BMI is defined as the measurement immediately prior to initiation of therapy and must be documented in the chart