CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Weight loss medications – Saxenda (liraglutide) and Wegovy (semaglutide)

Policy defines prior authorization, documentation, clinical eligibility, continuation criteria, quantity limits, and FDA dosing recommendations for Saxenda and Wegovy for commercial members. Applies to adults and pediatric patients (12+ where specified).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyWeight loss medications – Saxenda (liraglutide) and Wegovy (semaglutide)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2023

Next Review Date

Key ActionSubmit baseline weight and BMI, documentation of participation in a comprehensive weight management program with monthly follow-up for at least 6 months for initial requests; for continuation submit baseline and current weight/BMI and clinical notes documenting tolerability and continued lifestyle measures.

POLICY UPDATE CHANGES

No material clinical or coverage changes.

2Medications covered

6 moAuth duration (initial & cont.)

>=5%Adult response threshold

12Minimum pediatric age

Coverage Summary

Coverage stance: covered_with_criteria. Scope: policy applies to Saxenda (liraglutide) and Wegovy (semaglutide) for commercial members and defines prior authorization, documentation, clinical eligibility, continuation criteria, quantity limits, and FDA dosing recommendations. Populations covered: adults and pediatric patients aged 12 years and older where specified. Authorization duration: 6 months for both initial approval and continuation when criteria are met. Required documentation for initial requests includes baseline weight and BMI and clinical notes showing participation in a comprehensive weight management program with monthly follow-up for at least six months; continuation requests require baseline and current weight/BMI and clinical notes documenting tolerability and continued lifestyle measures. FDA dosing (per Definitions and FDA Dosage Recommendation): Wegovy maintenance is 1.7 mg or 2.4 mg once weekly; Saxenda maintenance per PI up to 3 mg daily (see FDA Dosage Recommendation section).

Key thresholds & quick facts

Adult BMI threshold - obesity>= 30 kg/m2

Adult BMI threshold - overweight + risk>= 27 kg/m2 plus at least one additional risk factor (e.g., coronary heart disease, type 2 diabetes, dyslipidemia, hypertension, sleep apnea)

Minimum pediatric age12 years (use Cole criteria to classify obesity standardized for age and sex)

Weight-loss response - adults (Wegovy/Saxenda)>= 5% reduction in baseline body weight after the stated induction period (Wegovy >=20 weeks; Saxenda >=16 weeks)

Weight-loss response - Saxenda pediatrics (12-17)>= 1% reduction in BMI from baseline after >=12 weeks on maintenance dose

Authorization duration6 months

Medications covered (count)2

Initial Therapy Criteria

Documentation required to initiate prior authorization

Submission of the following information is necessary to initiate the prior authorization review:

ALL of the following

Initial requests: documentation of baseline weight, body mass index (BMI), and clinical notes documenting current participation in a comprehensive weight management program with monthly follow up (e.g., behavioral modification, nutrition, physical activity) for at least the past six months.
Continuation of therapy requests: documentation of baseline & current weight and BMI.
Active participation in a comprehensive weight management program (e.g., behavioral modification, nutrition, physical activity) may be indicated if continued pharmacologic benefit is lacking.
May be requested for continuation when benefit lacking

Continuation Therapy Criteria

Continuation of Therapy (authorization of 6 months)

Authorization of 6 months may be granted when ALL of the following criteria are met:

ALL of the following

Clinical notes documenting tolerability of the medication and continued reduced calorie diet with increased physical activity.
Patient is not using medication in combination with any other GLP-1 receptor agonist
Continuation criteria vary by drug and age
- Wegovy (adults and pediatrics) and Saxenda (adults 18+)
  - Completed at least 20 weeks of Wegovy or 16 weeks of Saxenda and are currently being treated with the FDA-recommended maintenance dose
  - If 5% weight loss met, one of:
    Patient has continued to display weight loss
    Patient has achieved a normal BMI (18.5-24.9)BMI 18.5-24.9
    If patient has demonstrated no further weight loss, and the BMI is 25 or greater, documentation showing active participation in a comprehensive weight loss program is requiredBMI >= 25
    Limit of 1 approval with this criterion
- Saxenda (pediatric patients 12-17 years)
  - Completed at least 12 weeks of therapy on maintenance dose of Saxenda
  - Patient had at least a 1 percent reduction in BMI from baseline with documentation provided>= 1% BMI reduction
  - AND meets one of:
    Patient has continued to display weight loss
    Patient has achieved a normal BMI standardized for age and sex (see Appendix)normal BMI per Appendix
    If patient has demonstrated no further weight loss, and the BMI is classified as obese when standardized for age and sex, documentation showing active participation in a comprehensive weight loss program is required

Provider Actions / Prior Authorization

Prior Authorization

Prior authorization required with documentation

Prior authorization requires submission of baseline weight and BMI and clinical notes showing current participation in a comprehensive weight management program with monthly follow-up for at least the past six months for initial requests. For continuation requests, submit baseline and current weight and BMI and clinical notes documenting tolerability and continued lifestyle measures.

Baseline weight and BMI (initial)
Clinical notes confirming ≥6 months participation with monthly follow-up (initial)
Baseline and current weight and BMI (continuation)
Clinical notes documenting tolerability and continued lifestyle measures (continuation)

Documentation Required

Document participation in weight management program

Document active participation in a comprehensive weight management program that includes behavioral modification, nutrition, and physical activity with monthly follow-up. Clinical notes must show at least 6 months of program participation prior to initiating drug therapy.

Program components: behavioral modification, nutrition, physical activity
Minimum duration: at least 6 months of monthly follow-up before initiation

Documentation Required

Document weight-loss response for continuation

For continuation, document drug-specific duration on maintenance dose and the required weight-loss response: Wegovy requires completion of at least 20 weeks on Wegovy (on maintenance dose) with ≥5% weight loss; Saxenda for adults requires at least 16 weeks on Saxenda (on maintenance dose) with ≥5% weight loss; Saxenda for pediatric patients 12–17 requires at least 12 weeks on maintenance dose with ≥1% reduction in BMI from baseline. Provide documentation of these outcomes and related clinical notes.

Wegovy (adults & pediatrics): ≥20 weeks on Wegovy on maintenance dose AND ≥5% weight loss
Saxenda (adults ≥18): ≥16 weeks on Saxenda on maintenance dose AND ≥5% weight loss
Saxenda (pediatrics 12–17): ≥12 weeks on maintenance dose AND ≥1% BMI reduction

Billing Rule

Quantity limits

Enforce product-specific quantity limits as listed in the policy.

Saxenda: 5 pens per 30 days
Wegovy: 4 pens per 28 days

Clinical Evidence & References

Primary references: Saxenda PI (May 2023); Wegovy PI (July 2023). Guideline references cited in the policy: Endocrine Society clinical practice guideline (2015) and the 2013 AHA/ACC/TOS guideline for management of overweight and obesity in adults. Background notes: the policy was adapted from Saxenda and Wegovy FDA prescribing information and uses standard obesity management principles requiring lifestyle modification plus pharmacotherapy when criteria are met. Appendix provides the Cole criteria (International Obesity Task Force BMI cut-offs) for pediatric BMI thresholds.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyWeight loss medications – Saxenda (liraglutide) and Wegovy (semaglutide)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2023

Next Review Date

On This Page

Saxenda 18mg/3ml	Quantity limit: 5 pens per 30 days
Wegovy 0.25mg/0.5mg/1mg/1.7mg/2.4mg (pens)	Quantity limit: 4 pens per 28 days

OpenPayer

Weight loss medications – Saxenda (liraglutide) and Wegovy (semaglutide)

Coverage Summary

Initial Therapy Criteria

Continuation Therapy Criteria

Unproven / Exclusions

Applicable Codes

Provider Actions / Prior Authorization

Clinical Evidence & References

Background

Revision History