CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Weight loss medication coverage (Wegovy, Zepbound)

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Defines medical necessity criteria, dosing limits, and documentation requirements for coverage of Wegovy (semaglutide) and Zepbound (tirzepatide) for members of Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyWeight loss medication coverage (Wegovy, Zepbound)

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateJan 1, 2026

Last ReviewAug 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of baseline and current weight/BMI and evidence of participation in a comprehensive weight management program.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsInitial/continuation period

>=5%

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CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Weight loss medication coverage (Wegovy, Zepbound)

Customize your policy alerts

Sign up for all Neighborhood Health Plan of Rhode Island policy alerts

Know when Neighborhood Health Plan of Rhode Island releases new policies or updates existing guidance.

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Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyWeight loss medication coverage (Wegovy, Zepbound)

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateJan 1, 2026

Last ReviewAug 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of baseline and current weight/BMI and evidence of participation in a comprehensive weight management program.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsInitial/continuation period

>=5%

Required weight loss

4 pens/28dQuantity limit

0.25 mgWegovy initiation

2.5 mgZepbound initiation

Coverage Criteria for Wegovy and Zepbound

inv-01: Initial Therapy

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

Initial approval: Provider must document 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 patient performance

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Prescriber: Requested drug prescribed by, or in consultation with, a weight loss clinic or a dietician/nutritionist

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BMI criteria: ADULT: BMI >= 30 kg/m2 OR BMI >= 27 kg/m2 with at least one additional risk factor (e.g., coronary heart disease, type 2 diabetes, dyslipidemia, hypertension, sleep apnea). PEDIATRIC (>=12 years): BMI classified as obese for age and sex per International Obesity Task Force (Cole Criteria)

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Age and step therapy: For Zepbound requests the patient must be >= 18 years and must have experienced inadequate outcome, intolerance, or contraindication to Wegovy; for Wegovy requests the patient must be >= 12 years

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Dosing and quantity: Requested dosing must be within FDA recommended limits: once-weekly injections (no more than one injection every 7 days; quantity limit 4 pens per 28 days). Initial requested strength must match FDA initiation dosing (Wegovy initiation 0.25 mg; Zepbound initiation 2.5 mg). Maintenance strengths per FDA apply for continuation requests

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inv-02: Continuation Therapy

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

Tolerability and lifestyle: Documented tolerability of the medication and evidence that the patient is continuing a reduced calorie diet with increased physical activity

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No combination GLP-1: Medication is not used in combination with any other GLP-1 receptor agonist

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Weight response: At least 5% of baseline body weight loss while taking Wegovy or Zepbound (documentation of baseline and current weight and BMI required) AND one of the following: a) patient has continued to display weight loss; OR b) patient has achieved a normal BMI (18.5–24.9); OR c) if no further weight loss and BMI >= 25, documentation of active participation in a comprehensive weight loss program is provided (limit of 1 approval using this criterion)>=5%

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Use of Wegovy or Zepbound in combination with any other GLP-1 receptor agonist is disallowed. Requests that specify combination therapy with another GLP-1 receptor agonist will not meet coverage criteria and should be denied.

Requests for dosing or quantity that exceed one injection every seven days (more than 4 pens per 28 days) are not consistent with FDA dosing recommendations and are not supported by this policy.

Product Strengths, Limits, and Key Metrics

Product strengths (listed in policy, not billing codes) - Wegovymixed

Wegovy strengths listed

0.25 mg, 0.5 mg, 1 mg, 1.7 mg, 2.4 mg (subcutaneous injection)

Product strengths (listed in policy, not billing codes) - Zepboundmixed

Zepbound strengths listed

2.5 mg/0.5 ml, 5 mg/0.5 ml, 7.5 mg/0.5 ml, 10 mg/0.5 ml, 12.5 mg/0.5 ml, 15 mg/0.5 ml (subcutaneous injection)

Percent weight loss for continuation

Percent weight loss required>= 5% of baseline body weight

Documentation requiredDocumentation of baseline and current weight and BMI must be provided

Additional continuation optionsIf no further weight loss and BMI >=25, evidence of active participation in a comprehensive weight loss program is required (limit: 1 approval with this criterion)

Adult BMI threshold

Adult BMI threshold (primary)>= 30 kg/m2

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

Provider Requirements, Documentation, and Denial Risk

Prior Authorization

Prior authorization required for Wegovy and Zepbound

Prior authorization is required for both Wegovy and Zepbound. Requests must document active participation in a comprehensive weight management program, be prescribed by or in consultation with a weight-loss clinic or dietician/nutritionist, include baseline and current weight and BMI, and meet age and dosing initiation requirements (Wegovy ≥12 years; Zepbound ≥18 years).

Evidence of current, active participation in a comprehensive weight management program (meets at least monthly for 6 months)
Prescribed by or in consultation with a weight loss clinic or a dietician/nutritionist
Documentation of baseline and current weight and BMI
Age: Zepbound requests — patient ≥18 years; Wegovy requests — patient ≥12 years
Requested strength must be consistent with FDA initiation dosing (see dosing callout)

Step Therapy

Zepbound requires trial/intolerance of Wegovy for initial requests

Background on Agents and Indications

Wegovy (semaglutide) and Zepbound (tirzepatide) are injectable agents related to the GLP-1/GIP class indicated for weight management. This policy aligns prior authorization and continuation requirements with FDA-recommended initiation and maintenance dosing, requires documentation of BMI and participation in a comprehensive weight management program, and restricts use to the approved age groups and dosing schedules.

Definitions Used in This Policy

Obese (pediatric)

Definition (pediatric obesity)For pediatric patients 12 years and older, obesity is defined using International Obesity Task Force (Cole Criteria) BMI cut-offs standardized by age and sex.

Applicable agesApplies only to patients aged 12 years and older for policy criteria

Reference tableSee Appendix Table 2 (Cole Criteria) for specific BMI cut-offs by sex and age

Comprehensive weight management program

Core componentsBehavioral health counseling, dietary/nutritional education/counseling, and reinforcement/advocacy for an exercise regimen

Minimum program frequencyMeets at least monthly for 6 months prior to using drug therapy

Revision History

2026-01-01Effective dateLatest

Policy effective date set to 01/2026.

2025-08Review

Policy reviewed in 08/2025 as documented in the source.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyWeight loss medication coverage (Wegovy, Zepbound)

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateJan 1, 2026

Last ReviewAug 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of baseline and current weight/BMI and evidence of participation in a comprehensive weight management program.

SourceLink

On This Page

Maintenance dosing timing: Patient has completed at least 20 weeks of therapy for continuation requests where maintenance dosing is being requested20 weeks

Documentation requiredDocumentation of baseline weight and BMI must be provided

Pediatric BMI threshold

Pediatric age rangeApplies to patients 12 years of age and older

Pediatric BMI thresholdBMI classified as obese for age and sex per International Obesity Task Force (Cole Criteria)

Documentation requiredDocumentation of baseline weight and BMI must be provided

Quantity limit

Quantity limit4 pens per 28 days

Dose frequency equivalentOne injection every seven days (consistent with FDA recommended dosing limit)

Non-covered requestsRequests exceeding one injection every seven days (more than 4 pens/28 days) are not supported

For initial Zepbound requests the patient must have experienced an inadequate outcome, intolerance, or contraindication to Wegovy; this step requirement must be documented.

Documentation Required

Documentation of baseline/current weight, BMI, and program participation required

Provide documentation of baseline and current weight and BMI, and evidence of participation in a comprehensive weight management program that includes behavioral health counseling, dietary/nutritional counseling, and reinforcement/advocacy for an exercise regimen (program meets at least monthly for 6 months and tracks performance). Also include prescriber specialty or consultation with a weight loss clinic or dietician/nutritionist.

Documentation of baseline and current weight and BMI
Evidence of participation in a comprehensive weight management program (behavioral, dietary, exercise) meeting at least monthly for 6 months and tracking patient performance
Prescriber is the weight-loss clinic or consultation with a dietician/nutritionist

Billing Rule

Submit requested strength and evidence of FDA-consistent initiation/titration and quantity limits

For dosing and quantity approval submit the requested product strength and show that dosing follows FDA initiation and titration: Wegovy initiation 0.25 mg once weekly (with escalation per label) and Zepbound initiation 2.5 mg once weekly (with maintenance dosing per label). Also confirm quantity does not exceed four pens per 28 days.

Requested strength consistent with FDA initiation dosing: Wegovy 0.25 mg; Zepbound 2.5 mg
Show titration/maintenance per FDA label (Wegovy maintenance 1.7 or 2.4 mg; Zepbound maintenance 5, 10, or 15 mg)
Quantity limit: 4 pens per 28 days

Denial Risk

Denial risk if program participation not documented

Requests may be denied if documentation does not demonstrate active participation in a comprehensive weight management program that includes behavioral, dietary, and exercise components meeting at least monthly for 6 months and tracking performance.

Denial Risk

Continuation denials possible if tolerability, lifestyle, or weight‑loss criteria not met

Continuation requests may be denied if there is not documented tolerability, evidence of continued reduced‑calorie diet with increased physical activity, or documentation of at least 5% weight loss from baseline (with required supporting baseline and current weight/BMI).

Documented tolerability of the medication
Continued reduced calorie diet and increased physical activity
Documentation of ≥5% of baseline body weight loss with baseline and current weight/BMI provided (and one of: continued loss, achieved normal BMI, or active program participation if BMI ≥25)

Documentation expectationProgram must track the patient’s performance and efficacy