CurrentDenver-Health-Medical-PlanPolicy N/A

Weight Loss Medication and GLP-1 Checklist

Defines coverage and prior authorization requirements for weight loss medications and GLP-1 agonists across Denver Health Medical Plan lines of business (Medicare, Medicaid/CHP, Commercial, Exchange). Intended for pharmacy, prescribing clinicians, and prior authorization staff.

Policy Summary

PayerDenver-Health-Medical-Plan

PolicyWeight Loss Medication and GLP-1 Checklist

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionWhen submitting prior authorization requests for covered weight loss products, document the FDA-indicated diagnosis, current BMI/weight (within 90 days), required chart notes and program participation, verify contraindications/interactions via Micromedex, and submit PAs via fax or Epic (email not accepted).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medicare & Medicaid/CHPLines where weight loss is excluded

Commercial & ExchangeLines where weight loss medications are covered (with exceptions)

≥7Named weight loss products listed

Coverage Criteria & Line-of-Business Rules

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

ANY of the following

Medicare (DHM01) and Medicaid/CHP (DHM02/03): Weight loss is an excluded (not covered) benefit
No coverage for weight loss indication under these LOBs
Commercial (DHM04) and Exchange (DHM08/09): Certain weight loss products are covered, with prior authorization required for products marked with *
See product-specific PA criteria

Commercial/Exchange PA requirements (general GLP-1 and weight-loss PA expectations)

Provider must meet documentation and clinical requirements when requesting PA for covered products (Commercial and Exchange lines):

ALL of the following

Prescribed for an FDA-indicated diagnosis
Current BMI and weight documented (current defined as within last 90 days)within the last 90 days
Chart notes used as documentation
Contraindications listed in package insert verified by Micromedex and charted in medical record
Intolerable side effects must be charted with start and end dates (hypothetical situations are not accepted)
Time between Health Lifestyle Clinic (HLC) visits cannot exceed 90 days; at least two visits in the last 6 monthsAt least two visits in the last 6 months; no interval > 90 days between visits
Comprehensive weight loss program documentation (at least documentation of program participation expected)
- Nutritional guidance
- Regular physical activity
- Behavioral therapy
- Medical supervision
- Support systems
Major drug interactions must be verifiable by Micromedex and documented

T2DM-specific GLP-1 requirements (Commercial plans)

For GLP-1s indicated for Type 2 diabetes mellitus under Commercial plans, PA criteria require additional diabetes-specific documentation:

ALL of the following

FDA-indicated diagnosis of Type 2 diabetes mellitus
Documentation of uncontrolled A1C before therapy per ADA guidelines
Previous trial and failure of metformin
Product-specific additional requirement
- Trulicity requires previous failure of at least two other GLP-1s indicated for T2DM

Actions Providers Must Take

Prior Authorization

Prior Authorization required for specified products

Prior authorization is required for the listed weight-loss products on Commercial and Exchange lines of business. Providers must submit PA requests via fax or Epic (email PAs are not accepted). Additional product-specific PA criteria are posted on the payer website.

Contrave
Imcivree
Orlistat
Plenity
Qsymia
Saxenda (liraglutide)
Wegovy (semaglutide)
Zepbound (tirzepatide)

Documentation Required

Essential documentation to support PA

Include clinical and program documentation to support the PA: diagnosis and recent anthropometrics, charted contraindications/side effects with dates, evidence of participation in a comprehensive weight loss program, and Micromedex verification of contraindications or major interactions.

FDA-indicated diagnosis
Current BMI and weight (current = within the last 90 days)
Chart notes documenting contraindications from the package insert (verifiable in Micromedex)
Chart notes documenting intolerable side effects with start and end dates (no hypothetical situations)
Evidence of participation in a comprehensive weight loss program (nutritional guidance, regular physical activity, behavioral therapy, medical supervision, support systems)
Micromedex verification of major drug interactions or contraindications
HLC visit documentation: at least two visits in the last 6 months with no interval > 90 days

Documentation Required

Diabetes-specific documentation for commercial GLP-1s

For commercial GLP-1 requests for Type 2 diabetes, submit diabetes-specific data: A1C demonstrating uncontrolled diabetes per ADA guidelines and evidence of a prior metformin trial and failure. For Trulicity, include documentation showing failure of at least two other GLP-1s indicated for T2DM.

A1C showing uncontrolled diabetes per ADA guidance
Prior trial and failure of metformin
Trulicity: prior failure of at least two other GLP-1s indicated for T2DM

Billing Rule

PA submission channels

Administrative submission requirements: PAs will no longer be accepted via email — submit PA requests via fax or Epic. Confirm the correct fax number on the PA form to avoid misdirected outreach.

Do not submit PAs via email; use fax or Epic.
Verify the fax number on the PA form to ensure outreach is routed correctly.

Named Products & Equivalency Mapping

Named covered or listed products (Commercial & Exchange — coverage varies by LOB)mixedCovered

Contrave	Listed as covered product; PA required
Imcivree	Exchange LOB only; PA required
Orlistat	Exchange LOB only; coverage noted
Phentermine	Listed as covered product
Plenity	Exchange LOB only; PA required
Qsymia	Listed as covered product; PA required
Saxenda (liraglutide)	Listed as covered product; PA required
Wegovy (semaglutide)	Listed as covered product; PA required
Zepbound (tirzepatide)	Exchange LOB only; PA required

GLP-1 product equivalency notes / mappingmixed

Bydureon Bcise (exenatide ER)	Weight loss mapping: Wegovy (Semaglutide)
Byetta (exenatide)	Weight loss mapping: Saxenda (Liraglutide)
Ozempic (semaglutide)	Weight loss mapping: Zepbound (Tirzepatide)
Rybelsus (semaglutide)	Weight loss mapping: not specified
Trulicity (dulaglutide)	Weight loss mapping: not specified
Victoza (liraglutide)	Weight loss mapping: not specified
Mounjaro (tirzepatide)	Weight loss mapping: not specified
Adlyxin (lixisenatide)	Weight loss mapping: not specified

Clinical & Plan Background

This policy addresses coverage for GLP-1 agonists and other weight loss medications across Denver Health Medical Plan lines of business. GLP-1 agonists are used for management of Type 2 diabetes mellitus (T2DM) and, for certain agents, for chronic weight management. Some GLP-1s are approved only for T2DM while others are approved only for weight loss; the plan distinguishes coverage based on the drug’s FDA indication.

Coverage varies by line of business: Medicare (DHM01) and Medicaid/CHP (DHM02/03) — weight loss is an excluded (not covered) benefit. Commercial (DHM04) and Exchange (DHM08/09) — weight loss medications may be covered, but coverage depends on the specific product and often requires prior authorization (PA). The policy lists named weight loss products and identifies which are covered and which require PA, and notes certain products are Exchange-only.

For Commercial and Exchange PA requests, providers must supply clinical documentation supporting the FDA-indicated diagnosis, recent anthropometric data, and program participation details. For GLP-1 use in T2DM under Commercial plans, additional diabetes-specific documentation is required (including evidence of uncontrolled A1C per ADA guidance and prior metformin use; Trulicity has an additional requirement of prior failure of at least two other GLP-1s for T2DM). PA submission must follow current channels (fax or Epic) as email is no longer accepted.