CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Weight Loss Management — Contrave, Wegovy, Zepbound (Coverage Criteria)

Defines medical necessity criteria, initiation and continuation requirements, prescribing specialty, and dosing/quantity limits for Contrave (naltrexone/bupropion), Wegovy (semaglutide), and Zepbound (tirzepatide) for Medicaid members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyWeight Loss Management — Contrave, Wegovy, Zepbound (Coverage Criteria)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document active participation in a comprehensive weight management program (monthly for 6 months) with baseline and current weight/BMI.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3drugs covered (Contrave, Wegovy, Zepbound)

6 monthsinitial authorization interval described

>=27/>=30BMI thresholds referenced

20 weeksminimum therapy duration before continuation

5%weight loss threshold for continuation

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Coverage Criteria

Initial Therapy

Covered when ALL of the following are met:

Initial Approval - Weight Reduction: 1) Documentation of current, active participation in a comprehensive weight management program that includes behavioral health counseling, dietary/nutritional education/counseling, and reinforcement/advocacy for an exercise regimen; program meets at least monthly for 6 months and tracks patient performance and efficacy (baseline weight and BMI must be provided). 2) Baseline BMI criteria: adults with BMI >=30 kg/m2 OR adults with BMI >=27 kg/m2 plus at least one additional risk factor (coronary heart disease, type 2 diabetes, dyslipidemia, hypertension, sleep apnea); pediatric patients age >=12 with BMI classified as obese for age/sex (Cole criteria). 3) Drug- and age-specific restrictions: Contrave and Zepbound require the patient be >=18 years when specified; verify product-specific age limits. 4) For Wegovy or Zepbound, patient is NOT using the requested agent in combination with any other GLP-1 receptor agonist. 5) For Wegovy MACE risk-reduction requests: patient is >=18 years, documentation that the patient will be treated with Wegovy in combination with reduced calorie diet and increased physical activity, documentation that the patient does NOT have type 2 diabetes, and documentation of established cardiovascular disease per policy. 6) For Zepbound OSA indication (adults >=18): documentation of moderate-to-severe OSA with AHI >=15 on polysomnography and documentation of prior CPAP treatment for at least one month with residual sleepiness despite compliance.

Continuation Therapy

Covered when ALL continuation conditions are met:

Continuation Approval: 1) Clinical notes documenting tolerability of the medication and continued adherence to a reduced-calorie diet with increased physical activity. 2) Patient completed the required trial period and is currently on the FDA-recommended maintenance dose: at least 20 weeks of therapy for Wegovy or Zepbound (16 weeks for Contrave or Saxenda where applicable). 3) Demonstrated efficacy: patient has lost >=5% of baseline body weight while on therapy OR achieved a normal BMI (18.5–24.9) OR continues to display ongoing weight loss. If no further weight loss and BMI >=25, documentation of active participation in a comprehensive weight loss program is required (limit of one approval under this criterion). 4) For Wegovy continued use for MACE risk reduction: documentation of ongoing established cardiovascular disease, continuation with diet/exercise, and documentation that the patient does NOT have type 2 diabetes; documentation of receipt of guideline-directed medical therapy for CVD or reason for not using GDMT. 5) For Zepbound continuation for OSA: prior documentation of moderate-to-severe OSA, currently on FDA maintenance dose, and documentation of treatment efficacy (reduced daytime sleepiness, fewer arousals, reduced snoring) and tolerability.

Prescriber Specialty

Covered when prescribed by appropriate clinicians:

Prescriber: For OSA in patients with obesity: the request must be prescribed by, or in consultation with, a weight loss clinic or a dietician/nutritionist with supporting specialist documentation. For weight reduction: the request must be prescribed by, or in consultation with, a weight loss clinic or a dietician/nutritionist.

Requests for Wegovy (semaglutide) or Zepbound (tirzepatide) in combination with any other GLP-1 receptor agonist are excluded. The policy requires documentation that the patient is not using the requested medication in combination with any other GLP-1 receptor agonist, and such combination therapy may be denied.

For the Wegovy MACE-risk reduction indication the policy specifically requires documentation that the patient does NOT have type 2 diabetes. The source notes that Ozempic (semaglutide for T2DM) is indicated to reduce major cardiovascular events in adults with type 2 diabetes and established cardiovascular disease, and patients with type 2 diabetes may instead be treated with Ozempic for cardiovascular risk reduction — therefore Wegovy’s MACE indication requires absence of T2DM to meet coverage criteria.

Clinical Thresholds and Coding

Adult BMI threshold

Adult BMI thresholdAdults: BMI >= 30 kg/m2 OR BMI >= 27 kg/m2 with at least one additional cardiovascular/metabolic risk factor (e.g., coronary heart disease, type 2 diabetes, dyslipidemia, hypertension, sleep apnea).

Documentation requiredBaseline weight and BMI must be provided in the request.

Age considerationSome drugs (Contrave, Zepbound) require the patient be >=18 years for certain indications — confirm drug-specific age limits in criteria.

Pediatric BMI threshold

Pediatric BMI threshold (age 12+)Patients aged >=12 years: BMI classified as obese using age- and sex-standardized International Obesity Task Force (Cole) criteria (see Cole table).

Documentation requiredProvide baseline weight and BMI and indicate Cole classification for age and sex.

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Initial approvals may be granted for up to 6 months when all initiation criteria are met.

Initial authorization: up to 6 months when all initiation criteria met
Requests for Wegovy or Zepbound must not be combined with another GLP-1 receptor agonist

Documentation Required

Comprehensive Weight Management Program Required Before Drug

A comprehensive weight management program is required before initiating therapy. The program must include behavioral health counseling, dietary/nutritional education or counseling, and reinforcement of an exercise regimen, and must meet at least monthly for 6 months to document active participation and track performance/efficacy.

Program components: Behavioral Health Counseling; Dietary/Nutritional education/counseling; Exercise reinforcement/advocacy

Background

This policy covers three pharmacologic agents for weight management: Contrave (naltrexone/bupropion), Wegovy (semaglutide), and Zepbound (tirzepatide). These agents are intended for use in combination with a reduced-calorie diet, increased physical activity, and a comprehensive weight management program that includes behavioral counseling, dietary/nutritional education, and exercise advocacy. The document specifies baseline BMI requirements for initiation, documents specific indications such as major adverse cardiovascular event (MACE) risk reduction for Wegovy (with the requirement that the patient does not have type 2 diabetes), and an obstructive sleep apnea (OSA) indication for Zepbound with OSA severity and prior CPAP trial requirements. Continuation criteria emphasize tolerability and clinical benefit (for example, demonstrated weight loss or symptom improvement) and require adherence to maintenance dosing and ongoing participation in the weight management program.

Definitions

Pediatric obesity BMI thresholds (Cole criteria)

Reference standardInternational Obesity Task Force (Cole) BMI cut-offs for obesity by sex and age for pediatric patients aged 12 years and older (see Table 2/Cole Criteria).

Use in assessmentsApply age- and sex-specific Cole cut-offs to classify BMI status for patients aged >=12 when requesting therapy.

DocumentationInclude the Cole table classification or calculated Cole cut-off used for the patient’s exact age and sex in the request.

Established cardiovascular disease (CVD)

Established CVD — componentsHistory of prior myocardial infarction (MI) or prior stroke qualifies as established cardiovascular disease.

Symptomatic peripheral arterial disease (PAD)Symptomatic PAD evidenced by intermittent claudication with ankle-brachial index (ABI) < 0.85 at rest, prior peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease.