Mass General Brigham Health Plan weight-loss coverage | OpenPayer
CurrentMass General Brigham Health PlanPolicy N/A
Coverage criteria for pharmacy benefit weight-loss medications
Prior authorization and coverage criteria for pharmacy benefit weight-loss medications (Alli, Contrave, Qsymia, Saxenda, Wegovy, Zepbound) for Mass General Brigham Health Plan members; governs initial and continuation authorization, quantity limits, and combination restrictions.
Policy Summary
PayerMass General Brigham Health Plan
PolicyCoverage criteria for pharmacy benefit weight-loss medications
Policy CodePolicy N/A
Change TypeMaterial updates with added agents, pediatric criteria, reauthorization thresholds
Effective Date09/01/2025
Next Review DateN/A
Key ActionObtain prior authorization and document baseline BMI and required weight-loss or stability evidence for initial and continuation approvals.
Zepbound (tirzepatide) and pediatric criteria for Qsymia were added.
Wegovy was added as the only agent approved for reduction of major adverse cardiovascular events in appropriate patients.
Reauthorization criteria were changed to require documented minimum percent weight loss thresholds and use as adjunct to lifestyle modifications.
Policy updated to allow authorization for members new to the plan (within 90 days) who are currently receiving and stable on treatment.
Quantity limits for the listed weight loss products were added to the policy.
6weight loss medications listed
6 monthstypical approval length
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>=5% / >=4% / >=1%reauthorization thresholds
09/01/2025effective date
Wegovyauthorized for CV event reduction
Coverage Criteria for Weight-Loss Medications
Initial Therapy
Initial approval: Authorization may be granted for members new to plan who are stable or when ALL diagnosis- and agent-specific criteria below are met.
Initial approval pathways: Authorization may be granted if member is new to the plan within the last 90 days and is currently receiving and stable on the requested treatment (samples and manufacturer assistance excluded) OR when all diagnosis- and agent-specific criteria below are met.
See new-to-plan allowance and full criteria
Pediatric criteria for Wegovy and Qsymia (ages 12-17): Member is 12–17 years of age AND medication is being used for appetite suppression or weight loss AND baseline BMI at or above the 95th percentile for age and sex (obesity) AND member is currently participating in an outpatient weight-loss program (e.g., dietary/caloric restrictions, exercise, behavioral support, community-based program).
See Wegovy and Qsymia pediatric criteria
Saxenda pediatric criteria (ages 12-17): Member is 12–17 years of age AND medication is being used for appetite suppression or weight loss AND body weight is greater than 60 kg AND baseline BMI corresponding to adult obesity (≈30 kg/m2 by international/Cole criteria) AND member is currently participating in an outpatient weight-loss program AND Saxenda will not be used in combination with a GLP-1 indicated for type 2 diabetes.
Saxenda pediatric specifics
Adult initial criteria (age ≥18): Medication is being used for appetite suppression or weight loss AND member meets ONE of: BMI ≥30 kg/m2 OR BMI ≥27 kg/m2 with at least ONE weight-related comorbidity (coronary heart disease, hypertension, dyslipidemia, type 2 diabetes mellitus, obstructive sleep apnea, obesity hypoventilation syndrome, pseudotumor cerebri, obesity-related cardiomyopathy, nonalcoholic steatohepatitis) AND member is currently participating in an outpatient weight-loss program (e.g., exercise, behavioral support, community-based program) AND member will maintain a low-calorie diet while on the requested medication AND for Saxenda, Wegovy, Zepbound: medication will not be used in combination with a GLP-1 indicated for treatment of type 2 diabetes.
Adult BMI/comorbidity and program participation requirements
Wegovy for reduction of major adverse cardiovascular events (secondary prevention): Member is ≥18 years of age AND treatment is requested to reduce the risk of major adverse cardiovascular events (cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke) AND member has established cardiovascular disease evidenced by at least ONE of prior myocardial infarction, prior stroke (including TIA), or peripheral arterial disease (e.g., intermittent claudication with ABI <0.85, peripheral revascularization, or amputation due to atherosclerotic disease) AND BMI ≥27 kg/m2 AND requested medication will be used as an adjunct to lifestyle modification AND member will not use requested medication in combination with a GLP-1 indicated for the treatment of type 2 diabetes.BMI ≥27 kg/m2
Wegovy CV prevention pathway
Continuation Therapy
Continuation of therapy: Requests for reauthorization will be approved when ALL diagnosis-specific criteria below are met.
General continuation requirements: Requested drug is being used as an adjunct to lifestyle modification (e.g., dietary/caloric restriction, exercise, behavioral support, community-based program) AND treatment is being requested for appetite suppression or weight loss.
General adjunct-to-lifestyle requirement
Saxenda continuation: For requests for Saxenda: If member has been administering Saxenda for up to 6 months, member has had a weight loss of at least 1% from baseline body weight or BMI. If member has been administering Saxenda for greater than 6 months: pediatric members (12–17 years) must be continuing to experience or maintain weight loss of at least 1% from baseline body weight or BMI; adult members (≥18 years) must be continuing to experience or maintain weight loss ≥4% of baseline body weight. Saxenda will not be used in combination with a GLP-1 indicated for type 2 diabetes.≤6 months: ≥1% from baseline; >6 months pediatric: ≥1%; >6 months adult: ≥4%
Saxenda reauthorization thresholds and combination restriction
The plan restricts simultaneous use of multiple GLP-1 receptor agonists: members are not permitted to fill more than one GLP-1 agonist or more than one GLP-1 agonist strength at one time. Requests for combinations of a GLP-1 agent indicated for type 2 diabetes together with a GLP-1 agent used for weight loss will not be authorized. In addition to GLP-1 combination restrictions, the policy limits certain agents to their labeled indications and dosing/quantity limits as specified under the Limitations section.
Wegovy (semaglutide) is the only agent under this policy authorized for the indication of reduction of risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke). Use of any other listed weight-loss agent for cardiovascular event risk reduction is not approved by this policy.
Clinical Thresholds and Coding Guidance
BMI and pediatric percentile thresholds — adult BMI thresholds and pediatric BMI percentile criteria for authorization; include Wegovy cardiovascular criteria pointer.
Adult BMI thresholdsAdults: BMI >=30 kg/m2 OR BMI >=27 kg/m2 with at least one weight-related comorbidity
Pediatric BMI percentilePediatrics (selected agents including Wegovy and Qsymia): baseline BMI at or above the 95th percentile for age and sex
Wegovy cardiovascular indication pointerWegovy is authorized for reduction of major adverse cardiovascular events in adults with established cardiovascular disease and BMI >=27 kg/m2 (see established CVD criteria)
Participation requirementMember must be participating in an outpatient weight‑loss program (dietary/caloric restriction, exercise, behavioral support) when pediatric criteria apply
Reauthorization weight-loss thresholds — numeric thresholds by agent and timing
Provider Requirements and Operational Notes
Prior Authorization
Prior Authorization Required
Prior authorization is required for all listed anti-obesity agents. Approvals are granted only when diagnosis, age, BMI/BMI percentile, and required documentation criteria are met. Members new to the plan (joined within the last 90 days) who are currently receiving treatment and are clinically stable may be eligible for authorization (product obtained as samples or via manufacturer patient assistance programs are excluded). Initial and reauthorization approvals may be granted for up to 6 months.
New-to-plan exception: member enrolled within last 90 days and currently stable on therapy (exclude samples/PAP)
Approval duration: up to 6 months
Step Therapy
Step Therapy
Step therapy requirements have been removed for Qsymia (no longer required to step through individual agents). There is no general step-through requirement for the listed agents; however, members are still subject to prior authorization and the policy clinical criteria. For members new to the plan, documentation that the member is currently receiving and stable on therapy supports approval under the new-to-plan pathway.
Definitions Used in Criteria
Established cardiovascular disease — list what qualifies (prior MI, prior stroke, symptomatic PAD) for secondary prevention criteria.
Prior myocardial infarction (MI)History of prior myocardial infarction as documented in the medical record
Prior strokePrior stroke including transient ischemic attack, ischemic or hemorrhagic stroke
Symptomatic peripheral arterial diseaseSymptomatic PAD (e.g., intermittent claudication with ankle‑brachial index <0.85, peripheral arterial revascularization, or amputation due to atherosclerotic disease)
Obesity/overweight criteria — adult and pediatric definitions used throughout the policy (BMI thresholds and percentile cutoffs).
Adult obesity definitionBMI >=30 kg/m2 (obesity)
Adult overweight with comorbidity
Clinical Background
This policy addresses coverage for several pharmacologic agents used as adjuncts to lifestyle modification for chronic weight management: orlistat (Alli), naltrexone/bupropion (Contrave), phentermine/topiramate extended‑release (Qsymia), liraglutide (Saxenda), semaglutide (Wegovy), and tirzepatide (Zepbound). These medications are intended to be used together with reduced‑calorie diet and increased physical activity and are subject to the policy’s prior authorization, continuation, and quantity‑limitation requirements.
Policy Summary
PayerMass General Brigham Health Plan
PolicyCoverage criteria for pharmacy benefit weight-loss medications
Policy CodePolicy N/A
Change TypeMaterial updates with added agents, pediatric criteria, reauthorization thresholds
Effective Date09/01/2025
Next Review DateN/A
Key ActionObtain prior authorization and document baseline BMI and required weight-loss or stability evidence for initial and continuation approvals.
For requests for Alli, Contrave, Qsymia, Wegovy, and Zepbound: If member has been administering the requested medication for up to 6 months, member has had a weight loss ≥5% of baseline body weight. If member has been administering the requested medication for greater than 6 months, member is continuing to experience or maintain weight loss ≥5% of baseline body weight. Wegovy and Zepbound will not be used in combination with a GLP-1 indicated for type 2 diabetes.
>=5%
Reauthorization thresholds for non-Saxenda agents and combination restriction for Wegovy/Zepbound
Wegovy continuation for CV prevention: When Wegovy is requested for reduction of major adverse cardiovascular events, requested medication must be used as an adjunct to lifestyle modification and member must not use Wegovy in combination with a GLP-1 indicated for type 2 diabetes.
Continuation pathway for Wegovy CV indication
Alli/Contrave/Qsymia/Wegovy/Zepbound (up to 6 months)
>=5% weight loss from baseline within up to 6 months of therapy
Alli/Contrave/Qsymia/Wegovy/Zepbound (>6 months)Continuing to experience or maintain >=5% weight loss from baseline after >6 months of therapy
Saxenda (up to 6 months)>=1% weight loss from baseline within up to 6 months of therapy
Saxenda (>6 months, pediatric)Continuing to experience or maintain >=1% weight loss from baseline (ages 12-17)
Saxenda (>6 months, adult)Continuing to experience or maintain >=4% weight loss from baseline (age >=18)
Qsymia: step therapy requirement removed — prior step-through not required
New-to-plan pathway: acceptance of current stable treatment as documentation in lieu of prior steps
Denial Risk
Triggers for Denial
Denial may be issued if required clinical or operational conditions are not met. Common triggers for denial include not meeting BMI/age/comorbidity thresholds, lack of documentation of participation in a lifestyle modification program (where required), failure to meet specified weight-loss thresholds for continuation, use of excluded drug combinations, or requests for coverage obtained via samples/PAP without evidence of stable treatment.
Age/BMI criteria not met (e.g., adult thresholds: BMI ≥30 kg/m2 or BMI ≥27 kg/m2 with ≥1 listed comorbidity; pediatric criteria for specified agents apply)
No documentation of participation in outpatient weight-loss program when required (exercise, behavioral support, community-based program)
Failure to meet reauthorization weight-loss thresholds (examples: ≥5% baseline weight loss for many agents by up to 6 months; Saxenda continuation thresholds detailed in clinical criteria)
Concurrent use of a GLP-1 for type 2 diabetes with a GLP-1 for weight loss when prohibited (e.g., Saxenda/Wegovy/Zepbound in combination with diabetes-indicated GLP-1s)
Request based on samples or manufacturer patient assistance program without proof of stable therapy
BMI >=27 kg/m2 with at least one weight‑related comorbidity (e.g., coronary heart disease, hypertension, dyslipidemia, type 2 diabetes, OSA, NASH)
Pediatric obesity definitionBMI at or above the 95th percentile for age and sex (applies to select agents and pediatric criteria)
Saxenda pediatric additional requirementFor Saxenda in ages 12–17: body weight >60 kg and baseline BMI corresponding to adult BMI >=30 kg/m2 by international cutoffs