Weight Loss Medications: Contrave, Liraglutide (Saxenda), Wegovy (semaglutide) injection, Zepbound (tirzepatide)
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Prior authorization policy for pharmacy coverage of specified weight-loss medications for Mass General Brigham Health Plan commercial/exchange members; defines initial and continuation criteria, limitations, and documentation requirements.
Zepbound (tirzepatide) was added to the list of covered weight-loss medications requiring prior authorization.
Initial and reauthorization approvals may be granted for 6 months (previously 90 days for some agents).
Members are restricted from filling more than one GLP-1 agonist or more than one GLP-1 agonist strength at one time.
Authorization requires submission of medical records documenting current treatment or that criteria are met for all initial and reauthorization requests.
Coverage Criteria for Weight-Loss Medications
Initial Therapy
Authorization may be granted when ALL of the following diagnosis-specific criteria are met (see subgroup conditions):
Continuation of Therapy / Reauthorization
Requests for reauthorization will be approved when ALL of the following diagnosis-specific criteria are met:
The Plan will not authorize coverage of a GLP‑1 agonist used for the treatment of type 2 diabetes in combination with a GLP‑1 agonist used for weight loss. Requests that propose concurrent use of two GLP‑1 agents (including different agents or multiple strengths of the same agent) may be denied. Providers should verify member benefits, as coverage of obesity GLP‑1 agents is subject to the member’s plan document and may be limited by the benefit design.
For the indication of reducing the risk of major adverse cardiovascular events (cardiovascular death, non‑fatal myocardial infarction, or non‑fatal stroke), only Wegovy (semaglutide) will be approved under this policy. Other GLP‑1 or dual agonist agents are not authorized for the cardiovascular risk‑reduction indication.
Clinical Thresholds and BMI/Weight Criteria
Actions Required by Prescribers and Pharmacy
Prior authorization required
Prior authorization is required for Contrave, Liraglutide (Saxenda), Wegovy (semaglutide) injection, and Zepbound (tirzepatide) under the pharmacy benefit for commercial/exchange plans.
Step therapy
No step therapy requirement is specified in this policy.
Medical records required
Submit medical records (for example, chart notes) documenting current treatment and that the member meets all diagnosis-specific criteria for initial and reauthorization requests, including participation in a behavior modification program and measured baseline and follow-up weight/BMI as applicable.
- If member is new to the plan (coverage effective ≤90 days), include records showing current receipt of the requested drug.
- For reauthorization, provide documentation of weight-loss response per agent-specific thresholds (e.g., ≥5% for Contrave/Wegovy/Zepbound; Saxenda thresholds vary by age).
- Document that the member continues to participate in a behavior modification program.
Concurrent GLP‑1 fills and plan exclusion
Requests may be denied if the member attempts to fill more than one GLP‑1 agonist or more than one strength at the same time, or if the member's plan does not cover obesity GLP‑1s per the benefit documents.
- Members are restricted from filling more than one GLP-1 agonist or more than one GLP-1 agonist strength at one time.
- Coverage for GLP-1s indicated for weight management may vary by member plan; refer to plan documents for exclusions.
Definitions and Program Requirements
Background
These weight‑loss agents are indicated as adjuncts to a reduced‑calorie diet and increased physical activity for chronic weight management in patients with obesity or overweight with comorbidities. The policy covers the following medications subject to prior authorization: Contrave (naltrexone/bupropion), Liraglutide (Saxenda), Wegovy (semaglutide) injection, and Zepbound (tirzepatide). Wegovy additionally has a labeled indication for reducing major adverse cardiovascular events in adults with established cardiovascular disease and a BMI ≥27 kg/m2; per policy, approval for that use is limited to Wegovy.
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