Anti-obesity pharmacotherapy (Alli, Contrave, Qsymia, Saxenda, Wegovy, Zepbound) - Prior Authorization
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Prior authorization policy for pharmacy coverage of specified weight-management medications for commercial/exchange members of Mass General Brigham Health Plan, detailing initial and continuation criteria, age limits, quantity limits, and cardiac-risk indication for Wegovy.
Medical records are required to confirm that members meet all initial and reauthorization criteria for requested weight-management medications.
Reauthorization weight-loss thresholds updated to require ≥5% weight loss for most agents and agent-specific numeric thresholds for liraglutide (Saxenda).
Wegovy is the only agent approved under this policy for reduction of major adverse cardiovascular events.
Members are restricted from filling more than one GLP-1 agonist or more than one GLP-1 agonist strength at one time.
Coverage criteria
Initial Therapy — Weight Loss (Adults)
Authorization may be granted for members new to the plan who are stable on treatment or when ALL diagnosis-specific criteria are met:
Supports transient continuity of care
See child- and agent-specific exceptions below
Initial Therapy — Pediatrics (12-17)
For members 12-17 years of age, authorization requires MEDICAL RECORDS confirming ALL of the following:
Qsymia included for pediatric 12-17 per policy
Pediatric Saxenda has weight and BMI floor
Initial Therapy — Wegovy (Cardiovascular risk reduction)
Covered only for Wegovy when ALL of the following are met:
Policy limits CV indication to Wegovy only
Continuation of Therapy — Reauthorization criteria (ALL required)
Requests for reauthorization will be approved when ALL of the following diagnosis-specific criteria are met:
Agent-specific thresholds follow
Saxenda has distinct numeric thresholds
Applies to listed non-Saxenda agents
The policy prohibits concomitant use of a GLP-1 agonist prescribed for type 2 diabetes together with any GLP-1 agonist prescribed for weight loss. Requests that seek coverage for simultaneous treatment with a diabetes-indicated GLP-1 and a weight-loss–indicated GLP-1 will not be authorized.
Members are restricted from filling more than one GLP-1 agonist at a time and from filling more than one GLP-1 agonist strength simultaneously. Coverage may be considered not medically necessary when multiple GLP-1 agents or multiple strengths are used concurrently. Specific quantity limits for each product are listed in the policy limitations.
Coding and clinical thresholds
Provider actions and authorization workflow
Prior Authorization Required
Prior authorization is required for the listed weight-management agents. Initial and reauthorization approvals may be granted for up to 6 months. Authorization may be granted for members new to the plan within the last 90 days who are currently receiving treatment and are stable (excluding samples or manufacturer patient assistance). Medical records are required to confirm the member meets all diagnosis-specific initial or reauthorization criteria. Members are restricted from filling more than one GLP-1 agonist or more than one GLP-1 agonist strength at one time. Only Wegovy (semaglutide) will be approved for reduction of risk of major adverse cardiovascular events. Refer to member plan documents for coverage exceptions.
- Affected agents: Alli (orlistat); Contrave (naltrexone/bupropion); Qsymia (phentermine/topiramate ER); Liraglutide (Saxenda); Wegovy (semaglutide); Zepbound (tirzepatide).
- Initial and reauthorization approvals: up to 6 months.
- Contact (Medical Benefit): Phone 833-895-2611, Fax 888-656-6671. Pharmacy Benefit: Phone 800-711-4555, Fax 844-403-1029.
Step therapy
No step therapy is required per this policy.
Required documentation
Medical records must be provided to confirm the member meets all diagnosis‑specific initial or reauthorization criteria (including documentation of weight, diagnosis, prior treatments, participation in lifestyle/behavior modification program, and response to therapy where applicable). Failure to provide required medical records may result in denial.
- Required documentation examples: medical records showing diagnosis, baseline weight/BMI, documentation of lifestyle modification counseling or program participation, prior therapy history, and treatment response metrics for reauthorization.
- For Wegovy requested for reduction of major adverse cardiovascular events, records must confirm use as adjunct to lifestyle modification and that it will not be used in combination with a GLP-1 indicated for type 2 diabetes.
Triggers for denial
Triggers for denial include failure to provide required medical records and requests for prohibited combinations (for example, concurrent use of more than one GLP-1 agent, multiple strengths of a GLP-1, or combination of a GLP-1 for weight management with a GLP-1 indicated for type 2 diabetes).
- Denied if member attempts to fill >1 GLP-1 agonist or >1 strength at the same time.
- Denied if records show planned concurrent use of a GLP-1 indicated for weight loss with a GLP-1 indicated for type 2 diabetes.
- Denied if required medical records to support diagnosis-specific criteria are not provided.
Definitions
Background
These medications are covered as adjuncts to a reduced-calorie diet and increased physical activity for chronic weight management in overweight and obese patients. The policy notes that some agents have additional indications — for example, Wegovy (semaglutide) is the only agent approved under this policy for reduction of major adverse cardiovascular events in patients with established cardiovascular disease. Per recent updates, use of these agents for weight management requires documentation that the member is also participating in a behavior modification program and that treatment is used as an adjunct to lifestyle modification.
Revision history
Operationalized requirement that medical records must be submitted to confirm members meet all initial and reauthorization criteria for requested weight-management medications (documentation requirement).
Updated initial and reauthorization criteria to require medical records and participation in a behavior modification program; reflected generic availability of Saxenda and added quantity limits to the policy.
Added quantity limits to the policy (administrative update effective 09/01/2025).
Moved restriction that obesity GLP-1s will only be covered if the member's plan covers them into exceptions and clarified plan document referral; effective 07/01/2025.
Administrative change moving restriction prohibiting combination use of a GLP-1 indicated for weight loss with a GLP-1 indicated for type 2 diabetes into the criteria section; effective 07/01/2025.
Updated weight-loss reauthorization criteria to require either achieving the minimum weight-loss goal within up to six months or maintaining expected weight loss after more than six months; added adjunct-to-lifestyle requirement and prohibition on combining GLP-1s for diabetes with GLP-1s for weight loss.
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