CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Weight Loss Pharmacotherapy (Saxenda, Wegovy, Zepbound) Coverage Criteria

Defines clinical coverage and authorization criteria for liraglutide (Saxenda), semaglutide (Wegovy), and tirzepatide (Zepbound) for weight management, MACE risk reduction, and OSA-related obesity for commercial members of Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyWeight Loss Pharmacotherapy (Saxenda, Wegovy, Zepbound) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2023

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of active participation in a comprehensive weight management program and required baseline/current weight/BMI to support initial or continuation approval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsAuth period

>=30 or >=27Adult BMI threshold

5% weight lossContinuation response

20/16/12 wkMin therapy duration

4–5 pensQuantity limits

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Coverage and Medical Necessity Criteria

Initial Therapy (weight reduction)

Initial approval — Covered when ALL of the following are met for weight reduction (adult or pediatric as specified):

Comprehensive weight management program: Patient has current, active participation in a comprehensive weight management program that includes behavioral health counseling, dietary/nutritional counseling, and reinforcement/advocacy for an exercise regimen, meeting at least monthly for 6 months and tracking performance and efficacy.

BMI eligibility: One of: (1) patient (adult or pediatric ≥12 years) has BMI ≥30 kg/m2; (2) adult has BMI ≥27 kg/m2 plus at least one additional risk factor (e.g., coronary heart disease, type 2 diabetes, dyslipidemia, hypertension, sleep apnea); (3) pediatric (≥12 years) has BMI classified as obese when standardized for age and sex.

Product-specific age and combination restrictions: For Zepbound and Saxenda requests the patient must be ≥18 years of age; for Wegovy or Zepbound requests the patient must NOT be using medication in combination with any other GLP-1 receptor agonist.

Initial Therapy (Wegovy for MACE reduction)

Initial approval — Wegovy for MACE risk reduction when ALL of the following are met:

Wegovy MACE criteria: Requested drug is Wegovy; patient is ≥18 years of age; documentation that Wegovy will be used in combination with a reduced-calorie diet and increased physical activity; documentation of established cardiovascular disease (history of prior MI, prior stroke, symptomatic PAD evidenced by intermittent claudication with ABI <0.85 at rest, peripheral arterial revascularization, or amputation due to atherosclerotic disease; or prior coronary revascularization such as CABG/PCI/angioplasty); baseline BMI ≥27 kg/m2; patient does NOT have type 2 diabetes; and patient is receiving guideline-directed medical therapy (GDMT) for CVD or has a documented clinical reason not to be treated with GDMT.

Initial Therapy (Zepbound for OSA)

Initial approval — Zepbound for moderate to severe OSA in adults when ALL of the following are met:

Zepbound OSA criteria: Requested drug is Zepbound; patient is ≥18 years of age; patient meets the comprehensive weight management program participation requirement (behavioral, dietary/nutritional, exercise components, meeting at least monthly and tracking performance); BMI ≥30 kg/m2 or BMI ≥27 kg/m2 with at least one additional risk factor; documentation of moderate to severe OSA (e.g., apnea–hypopnea index ≥15 on polysomnography); patient has been treated with CPAP or airway obstruction treatment for at least one month with residual symptoms despite compliance; and patient is not using Zepbound in combination with another GLP-1 receptor agonist.

Continuation Therapy

Continuation of therapy — Covered when ALL of the following are met:

General continuation requirements: Clinical notes document tolerability of the medication and continued reduced-calorie diet with increased physical activity; and patient is not using medication in combination with any other GLP-1 receptor agonist.

Wegovy/Saxenda/Zepbound continuation (adults): Patient completed required trial period (Wegovy or Zepbound ≥20 weeks; Saxenda ≥16 weeks) and is currently being treated with the FDA‑recommended maintenance dose; AND patient lost ≥5% of baseline body weight with documentation provided AND one of: (1) patient has continued to display weight loss; (2) patient has achieved a normal BMI (18.5–24.9); (3) if no further weight loss and BMI ≥25, documentation of active participation in a comprehensive weight loss program is provided (limit of one approval with this criterion).

Saxenda continuation (pediatrics 12–17): Patient completed at least 12 weeks on maintenance Saxenda; AND patient had ≥1% reduction in BMI from baseline with documentation provided AND one of: (1) continued weight loss; (2) achieved a normal BMI standardized for age and sex; (3) if no further weight loss and BMI remains classified as obese for age/sex, documentation of active participation in a comprehensive weight loss program is provided (limit of one approval with this criterion).

Use of a GLP-1 receptor agonist in combination with any other GLP-1 receptor agonist is not permitted for approval. Providers must confirm that the patient is not using medication in combination with any other GLP-1 receptor agonist at both initial authorization and at continuation, and clinical documentation must reflect non‑use before coverage is granted.

Therapy will not be supported when required program participation, BMI or age thresholds, concurrent GLP‑1 use, or response/duration criteria are not met. Specifically, requests lacking documentation of active participation in a comprehensive weight management program (meeting at least monthly for 6 months), failure to meet the applicable BMI or age criteria (eg, adult BMI <30 and <27 with a risk factor, or pediatric age/sex standardized BMI not classified as obese), or use of the requested agent in combination with another GLP‑1 receptor agonist are not eligible for approval.

Continuation requests lacking evidence of the required treatment duration or clinical response are also not supported. For adults, continuation requires completion of the minimum trial period (Wegovy/Zepbound ≥ 20 weeks; Saxenda ≥ 16 weeks) and documented ≥ 5% reduction from baseline body weight (or meeting one of the alternate continuation conditions). For Saxenda in patients 12–17 years, continuation requires ≥ 12 weeks on maintenance dose and ≥ 1% reduction in BMI from baseline. Wegovy pathway for MACE excludes patients with type 2 diabetes per the policy criteria.

Product Limits, BMI & Response Thresholds

Covered NDC / Drug FormulationsmixedCovered

Saxenda 18mg/3mL	liraglutide - 5 pens per 30 days
Wegovy 0.25mg	semaglutide - 4 pens per 28 days
Wegovy 0.5mg	semaglutide - 4 pens per 28 days
Wegovy 1mg	semaglutide - 4 pens per 28 days
Wegovy 1.7mg	semaglutide - 4 pens per 28 days
Wegovy 2.4mg	semaglutide - 4 pens per 28 days
Zepbound 2.5mg/0.5mL	tirzepatide - 4 pens per 28 days
Zepbound 5mg/0.5mL	tirzepatide - 4 pens per 28 days
Zepbound 7.5mg/0.5mL	tirzepatide - 4 pens per 28 days
Zepbound 10mg/0.5mL	tirzepatide - 4 pens per 28 days

1–10 of 12

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BMI eligibility thresholds

Adult BMI threshold>= 30 kg/m2, or >= 27 kg/m2 with at least one obesity-related risk factor (e.g., coronary heart disease, type 2 diabetes, dyslipidemia, hypertension, sleep apnea)

Pediatric BMI thresholdAge 12–17: BMI classified as obese when standardized for age and sex (Cole criteria)

Weight-loss response for continuation

Adult weight-loss response (continuation)>= 5% reduction in baseline body weight after required trial period

Pediatric Saxenda response (continuation)>= 1% reduction in BMI from baseline after required maintenance period (ages 12–17)

Minimum therapy duration before assessing response

Prior Authorization, Documentation, and Denial Triggers

Prior Authorization

Prior Authorization Required

Prior authorization is required. Authorization of 6 months may be granted when all applicable initial or continuation criteria in the policy are met; approvals are granted for a 6-month period per authorization.

Approvals granted for up to 6 months per authorization
Prior authorization required before drug initiation

Documentation Required

Combination Therapy Restriction

Providers must confirm the patient is not using the requested agent in combination with any other GLP-1 receptor agonist at initiation and for continuation of therapy. This restriction applies to Wegovy, Saxenda, Zepbound, and other GLP-1 receptor agonists referenced in the policy.

Provider attestation that the patient is not concurrently using another GLP-1 receptor agonist (initial and continuation)
Applies to Wegovy, Saxenda, Zepbound and other GLP-1 receptor agonists

Clinical Background and Indications

This policy addresses pharmacologic agents used for weight management including liraglutide (Saxenda), semaglutide (Wegovy), and tirzepatide (Zepbound). Semaglutide (Wegovy) also has a defined pathway for reduction of major adverse cardiovascular events (MACE) in adults with established cardiovascular disease when the drug is used with a reduced‑calorie diet and increased physical activity and the patient meets the BMI and non‑diabetes requirements. Zepbound is included with specific criteria for treatment of moderate to severe obstructive sleep apnea (OSA) in adults with obesity. Coverage for these agents is tied to documented participation in a comprehensive weight management program, specified BMI and age thresholds, and evidence of clinical benefit on follow‑up.

Definitions and Pediatric Criteria

Pediatric obesity (age 12+)

Reference standardPediatric obesity for patients aged 12 years and older is defined using the International Obesity Task Force (Cole) BMI cut-offs standardized for age and sex (see Appendix Table 2)

Applicable agesApplies to pediatric patients aged 12 years and older

Use in continuation criteriaSaxenda pediatric continuation requires BMI classification per Cole criteria to determine achievement of normal BMI or persistent obesity