Weight Loss Medications: Contrave, Liraglutide (Saxenda), Wegovy (semaglutide) injection, Zepbound (tirzepatide)
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Pharmacy benefit prior authorization policy for weight management medications (Contrave, liraglutide/Saxenda, Wegovy/semaglutide, Zepbound/tirzepatide) including indications, coverage criteria, continuation, and limitations for Mass General Brigham Health Plan commercial/exchange members.
Added criteria for supplemental indication of MASH for Wegovy injection.
Require submission of medical records documenting positive clinical response or stability, adjunctive use with lifestyle modification, absence of cirrhosis, no co-administration with resmetirom for MASH, no combination use with GLP-1 agonists indicated for type 2 diabetes, and prescription by or in consultation with a gastroenterologist, hepatologist, or endocrinologist for Wegovy in MASH.
Clarified that obesity GLP-1s will only be covered if the member's plan covers them; refer to member plan documents.
Added quantity limits to the policy (administrative update).
Coverage and Authorization Criteria
Initial authorization criteria
Authorization may be granted when diagnosis- and age-specific criteria are met and required documentation is submitted.
Continuation of therapy
Reauthorization/continuation will be approved when medical records document diagnosis-specific continuation criteria, response thresholds, and ongoing participation in behavioral modification.
ALL of the following
General continuation
- Member is continuing to participate in a behavioral modification program (e.g., health coaching, nutritional counseling, community-based program).
Liraglutide (Saxenda) continuation thresholds
- For members 12-17 years: either (a) has been administering liraglutide for up to 6 months and has had weight loss ≥ 1% from baseline body weight or BMI, OR (b) has been administering liraglutide for >6 months and is continuing to experience or maintain weight loss ≥ 1% from baseline body weight or BMI.
- For members ≥18 years: either (a) has been administering liraglutide for up to 6 months and has had weight loss ≥ 4% from baseline body weight, OR (b) has been administering liraglutide for >6 months and is continuing to experience or maintain weight loss ≥ 4% from baseline body weight.
Contrave / Wegovy / Zepbound continuation thresholds
- Member has been administering the requested medication for up to 6 months and has had weight loss ≥ 5% of baseline body weight; OR has been administering the requested medication for >6 months and is continuing to experience or maintain weight loss ≥ 5% of baseline body weight.
Wegovy for MASH continuation
- For Wegovy prescribed for MASH, medical records must document positive clinical response to therapy or ongoing stability (e.g., improvement in LFTs, fibrosis stage improvement, improvement on MASH-specific imaging such as VCTE ≥ 25% relative change or MRE ≥ 20% relative change); member has not progressed to cirrhosis; medication is not being co-administered with Rezdiffra (resmetirom); medication is not being used in combination with a GLP-1 agonist indicated for treatment of type 2 diabetes; and medication is prescribed by or in consultation with a gastroenterologist, hepatologist, or endocrinologist.
Duration limits
- Initial approvals and reauthorizations: 6 months for weight loss and cardiovascular risk indications; 12 months for MASH indications.
Wegovy for MASH - Authorization Criteria
Wegovy (semaglutide) supplemental indication for MASH — authorization requires submission of medical records documenting response or stability and adherence to limits below.
ALL of the following
- Positive clinical response to therapy or ongoing stability (examples: improvement in liver function tests, fibrosis stage improvement, or improvement from baseline on MASH-specific imaging such as VCTE ≥ 25% or MRE ≥ 20%).
- Requested medication will be used as an adjunct to lifestyle modification (dietary/caloric restriction, exercise, behavioral support, community-based program).
- Member has not progressed to cirrhosis (e.g., no decompensated cirrhosis).
- Requested medication is not being co-administered with Rezdiffra (resmetirom) for the treatment of MASH.
- Requested medication is not being used in combination with a GLP-1 agonist indicated for the treatment of type 2 diabetes (e.g., liraglutide, Mounjaro, Ozempic, Rybelsus, Trulicity).
- Prescribed by or in consultation with one of the following specialists: gastroenterologist, hepatologist, or endocrinologist.
Product Limits, Response Thresholds, and Coding Notes
| Contrave tablet | 1 = 4 tablets per day |
| Liraglutide (Saxenda) pen | 1 = 5 pens per 30 days |
| Wegovy pen | 1 = 4 pens per 28 days |
| Zepbound pen | 1 = 4 pens per 28 days |
Required Actions, Documentation, and Billing Rules for Providers
Prior authorization required; new-member documentation for recent enrollments
Prior authorization is required under the pharmacy benefit for commercial/exchange members. If the member is new to the plan (coverage effective date ≤ 90 days), submit medical records documenting that the member is currently receiving the requested drug (exclude samples or manufacturer patient assistance program supplies).
Medical records and chart notes required
Submit medical records (e.g., chart notes) to document the diagnosis-specific criteria, baseline measures, and participation in a behavioral modification program; medical records are also required to support continuation requests.
- Documentation that treatment is for appetite suppression or weight loss
- Evidence of ongoing participation in behavioral modification
- For continuations, weight-loss response data per product-specific thresholds (see continuation criteria)
Quantity limits and prohibition on concurrent GLP-1s
Quantity limits and restrictions apply by product; members may not fill more than one GLP-1 agonist or more than one GLP-1 strength at one time.
- Contrave: 4 tablets per day
- Liraglutide (Saxenda): 5 pens per 30 days
- Wegovy pen: 4 pens per 28 days
- Zepbound pen: 4 pens per 28 days
- No concurrent use of multiple GLP-1 agonists or multiple strengths
Wegovy for MASH — required documentation and specialist prescribing/consultation
For Wegovy used for MASH, submit medical records documenting positive clinical response or ongoing stability (examples: improved LFTs, fibrosis stage improvement, MASH-specific imaging improvement), that therapy is adjunctive to lifestyle modification, that the member has not progressed to cirrhosis, and that the medication is not co-administered with resmetirom or with a GLP-1 for type 2 diabetes; prescription must be by or in consultation with a gastroenterologist, hepatologist, or endocrinologist.
- Document fibrosis stage F2–F3 confirmation (e.g., FIB-4 ≥ 1.3 plus ELF or LSM by VCTE, FAST, MAST, MEFIB, or liver biopsy within 12 months)
- Member counseled on limiting alcohol consumption
- Medication must not be used with Rezdiffra (resmetirom) or GLP-1s indicated for T2DM
Drug and Term Definitions
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