Drugs for Weight Management
Customize your policy alerts
Sign up for Premera Bluecross Policy 5.01.621 alerts
Get alerted when Policy 5.01.621 changes without checking for updates manually.
Monitor payer policy activity
Defines medical necessity criteria and usage limits for FDA-approved prescription drugs for chronic weight management (adults and pediatrics) as applied by Premera Bluecross pharmacy benefits.
No material clinical or coverage changes in this revision.
Product-specific Medical Necessity Criteria
Contrave — Contrave (naltrexone/bupropion) medical necessity criteria (adults)
Covered when ALL of the following are met:
ALL of the following
- Individual is aged 18 years or older.
- Has engaged in a trial of behavioral modification and dietary restriction for at least 3 months.
ALL of the following
ONE of
- BMI >= 30 kg/m2.
- BMI >= 27 kg/m2 AND at least one weight-related comorbidity.
- Medication is used as an adjunct to a reduced-calorie diet and increased physical activity.
- Dose is limited to four Contrave 8 mg/90 mg tablets per day (taken as two tablets in the morning and two tablets in the evening).
- Medication is not used concurrently with other medications intended for weight loss (e.g., Alli, benzphetamine, diethylpropion, liraglutide 18 mg/3 mL pen, phentermine, phentermine and topiramate extended-release, Qsymia, Saxenda, Wegovy, Xenical, Zepbound).
Comorbidities list
- Asthma
- Cardiovascular disease
- Chronic obstructive pulmonary disease (COPD)
- Coronary artery disease
- Dyslipidemia
- Hypertension
- Knee osteoarthritis
- Metabolic-dysfunction associated steatotic liver disease / non-alcoholic fatty liver disease
- Obstructive sleep apnea
- Polycystic ovarian syndrome
- Type 2 diabetes mellitus
Follow benefit plan for coverage availability; many benefit plans exclude drugs for weight management.
Foundayo — Foundayo (orforglipron) medical necessity criteria (adults)
Covered when ALL of the following are met:
ALL of the following
- Individual is aged 18 years or older.
- Has engaged in a trial of behavioral modification and dietary restriction for at least 3 months.
- Has a body mass index (BMI) >= 30 kg/m2 OR has a BMI >= 27 kg/m2 with one or more weight-related comorbid conditions (see comorbidities list).
- Does not have severe hepatic impairment (Child-Pugh Class C).
- Dose is limited to 17.2 mg daily.
- Quantity is limited to 30 tablets per 30 days.
- Medication is not used concurrently with other medications intended for weight loss.
- Medication is used as an adjunct to a reduced-calorie diet and increased physical activity.
Drugs for weight management may be excluded under many benefit plans; verify benefit coverage.
Liraglutide / Saxenda — Generic liraglutide 18 mg/3 mL pen and Saxenda (liraglutide) criteria (adult and pediatric)
Covered when ALL of the following are met (adult and pediatric criteria differ):
ALL of the following
- Adults: individual is aged 18 years or older.
- Pediatrics: individual is aged 12 to 17 years (when pediatric criteria apply).
- Has engaged in a trial of behavioral modification and dietary restriction for at least 3 months.
- Adults: BMI >= 30 kg/m2 OR BMI >= 27 kg/m2 with one or more weight-related comorbid conditions (see comorbidities list).
- Pediatrics: BMI >= 95th percentile for age and sex (see Appendix).
- Dose (adult) is limited to 3 mg per day and quantity is limited to 5 pens per 30 days.
- Medication is not used concurrently with other medications intended for weight loss.
- Medication is used as an adjunct to a reduced-calorie diet and increased physical activity.
Step requirement for Saxenda
- Has tried and had an inadequate response or intolerance to generic liraglutide 18 mg/3 mL pen (required before Saxenda).
Comorbidities list
- Asthma
- Cardiovascular disease
- Chronic obstructive pulmonary disease (COPD)
- Coronary artery disease
- Dyslipidemia
- Hypertension
- Knee osteoarthritis
- Metabolic-dysfunction associated steatotic liver disease / non-alcoholic fatty liver disease
- Obstructive sleep apnea
- Polycystic ovarian syndrome
- Type 2 diabetes mellitus
Pediatric use requires documentation of BMI percentile and a 3-month trial of behavioral modification; verify benefit coverage.
Phentermine and topiramate extended-release / Qsymia — criteria (adult and pediatric)
Covered when ALL of the following are met (adult and pediatric criteria):
ALL of the following
- Adults: individual is aged 18 years or older.
- Pediatrics: individual is aged 12 to 17 years (when pediatric criteria apply).
- Has engaged in a trial of behavioral modification and dietary restriction for at least 3 months.
- Adults: BMI >= 30 kg/m2 OR BMI >= 27 kg/m2 with one or more weight-related comorbid conditions (see comorbidities list).
- Pediatrics: BMI >= 95th percentile for age and sex.
- Dose is limited to 15 mg/92 mg daily (one capsule daily).
- For Qsymia (brand): has tried and had an inadequate response or intolerance to generic phentermine and topiramate extended-release (step requirement).
- Medication is not used concurrently with other medications intended for weight loss.
- Medication is used as an adjunct to a reduced-calorie diet and increased physical activity.
Comorbidities list
- Asthma
- Cardiovascular disease
- Chronic obstructive pulmonary disease (COPD)
- Coronary artery disease
- Dyslipidemia
- Hypertension
- Knee osteoarthritis
- Metabolic-dysfunction associated steatotic liver disease / non-alcoholic fatty liver disease
- Obstructive sleep apnea
- Polycystic ovarian syndrome
- Type 2 diabetes mellitus
Verify trial of generic product and benefit coverage per plan document.
Wegovy injection / Wegovy HD — Wegovy (semaglutide) injection and Wegovy HD criteria (adult, pediatric, and MACE indication)
Covered when ALL of the following are met (adult, pediatric, and MACE-specific criteria included):
ALL of the following
- Adults: individual is aged 18 years or older.
- Pediatrics: individual is aged 12 to 17 years (when pediatric criteria apply).
- Has engaged in a trial of behavioral modification and dietary restriction for at least 3 months.
- Adults (chronic weight management): BMI >= 30 kg/m2 OR BMI >= 27 kg/m2 with one or more weight-related comorbid conditions (see comorbidities list).
- Pediatrics: BMI >= 95th percentile for age and sex.
- Wegovy injection (chronic weight management adult dose limit): 7.2 mg once weekly; quantity limited to 4 pens per 28 days.
- Wegovy injection (pediatric dose limit): 2.4 mg once weekly; quantity limited to 4 pens per 28 days for pediatric use.
- Medication is not used concurrently with other medications intended for weight loss.
- Medication is used as an adjunct to a reduced-calorie diet and increased physical activity.
MACE indication
- Individuals aged >=18 years with BMI >=27 kg/m2.
- Has experienced a prior heart attack or stroke.
- Has symptomatic peripheral arterial disease evidenced by one of: intermittent claudication with ankle-brachial index < 0.85; peripheral arterial revascularization procedure; amputation due to atherosclerotic disease.
- Medication is used in combination with optimized drug therapy for established cardiovascular disease.
Comorbidities list
- Asthma
- Cardiovascular disease
- Chronic obstructive pulmonary disease (COPD)
- Coronary artery disease
- Dyslipidemia
- Hypertension
- Knee osteoarthritis
- Metabolic-dysfunction associated steatotic liver disease / non-alcoholic fatty liver disease
- Obstructive sleep apnea
- Polycystic ovarian syndrome
- Type 2 diabetes mellitus
For MACE indication, follow product-specific dosing limits and require combination with optimized cardiovascular therapy; verify benefit coverage.
Wegovy tablets — Wegovy (semaglutide) tablets criteria (adult and MACE)
Covered when ALL of the following are met (adult and MACE-specific criteria):
ALL of the following
- Individual is aged 18 years or older.
- Has engaged in a trial of behavioral modification and dietary restriction for at least 3 months.
- Has a body mass index (BMI) >= 30 kg/m2 OR BMI >= 27 kg/m2 with one or more weight-related comorbid conditions (see comorbidities list).
- Dose is limited to 25 mg daily and quantity is limited to 30 tablets per 30 days.
MACE criteria
- Age >= 18 years and baseline BMI >= 27 kg/m2.
- Has experienced a prior heart attack or stroke.
- Has symptomatic peripheral arterial disease evidenced by one of: intermittent claudication with ankle-brachial index < 0.85; peripheral arterial revascularization procedure; amputation due to atherosclerotic disease.
- Medication used in combination with optimized drug therapy for established cardiovascular disease.
- Medication is not used concurrently with other medications intended for weight loss.
- Medication is used as an adjunct to a reduced-calorie diet and increased physical activity.
Comorbidities list
- Asthma
- Cardiovascular disease
- Chronic obstructive pulmonary disease (COPD)
- Coronary artery disease
- Dyslipidemia
- Hypertension
- Knee osteoarthritis
- Metabolic-dysfunction associated steatotic liver disease / non-alcoholic fatty liver disease
- Obstructive sleep apnea
- Polycystic ovarian syndrome
- Type 2 diabetes mellitus
Quantity and dosing limits differ for tablet vs injection formulations; verify formulation-specific limits and benefit coverage.
Xenical / orlistat — Xenical (orlistat) and brand orlistat criteria (adult and pediatric)
Covered when ALL of the following are met (adult and pediatric criteria):
ALL of the following
- Adults: individual is aged 18 years or older.
- Pediatrics: individual is aged 12 to 17 years (when pediatric criteria apply).
- Has engaged in a trial of behavioral modification and dietary restriction for at least 3 months.
- Adults: BMI >= 30 kg/m2 OR BMI >= 27 kg/m2 with one or more weight-related comorbid conditions (see comorbidities list).
- Pediatrics: BMI >= 95th percentile for age and sex.
- Dose is limited to three 120 mg capsules daily (one capsule three times a day).
- Medication is not used concurrently with other medications intended for weight loss.
- Medication is used as an adjunct to a reduced-calorie diet and increased physical activity.
Comorbidities list
- Asthma
- Cardiovascular disease
- Chronic obstructive pulmonary disease (COPD)
- Coronary artery disease
- Dyslipidemia
- Hypertension
- Knee osteoarthritis
- Metabolic-dysfunction associated steatotic liver disease / non-alcoholic fatty liver disease
- Obstructive sleep apnea
- Polycystic ovarian syndrome
- Type 2 diabetes mellitus
Pediatric use requires BMI percentile documentation and a 3-month behavioral trial; verify benefit coverage.
Zepbound — Zepbound (tirzepatide) criteria (adults)
Covered when ALL of the following are met (adults):
ALL of the following
- Individual is aged 18 years or older.
- Has engaged in a trial of behavioral modification and dietary restriction for at least 3 months.
- Has a body mass index (BMI) >= 30 kg/m2 OR BMI >= 27 kg/m2 with one or more weight-related comorbid conditions (see comorbidities list).
- Medication is used as an adjunct to a reduced-calorie diet and increased physical activity.
- Dose is limited to 15 mg once weekly (maintenance dose up to 15 mg once weekly).
- Quantity limits: 4 prefilled pens or single-dose vials per 28 days OR 1 Kwikpen or multi-dose vial per 28 days (formulation-dependent).
- Medication is not used concurrently with other medications intended for weight loss.
Additional indication (OSA)
- Moderate to severe obstructive sleep apnea (OSA) in adults with obesity may be an indication when sleep study within past 12 months shows AHI >= 15 events/hour.
- Exclusions: not diagnosed with central sleep apnea with percent central events above defined threshold (see policy).
Comorbidities list
- Asthma
- Cardiovascular disease
- Chronic obstructive pulmonary disease (COPD)
- Coronary artery disease
- Dyslipidemia
- Hypertension
- Knee osteoarthritis
Re-authorization examples: >=5% baseline body weight loss after 7 months for chronic weight management; for OSA indication, >=10% weight loss after 12 months and stability in OSA symptoms.
inv-09: Medical necessity and re-authorization criteria by product — Product-specific medical necessity criteria, dosing/quantity limits, age/BMI thresholds, and re-authorization requirements.
Product-specific medical necessity criteria, dosing/quantity limits, age/BMI thresholds, and re-authorization requirements (high-level summary):
ALL of the following
- Orlistat (Xenical / brand orlistat): age 12–17 (pediatric) OR adults per labeling; pediatric trial of behavioral modification >=3 months; pediatric BMI >=95th percentile; adult BMI criteria >=30 or >=27+comorbidity; dose limited to three 120 mg capsules daily; not used concurrently with other weight-loss medications.
- Zepbound (tirzepatide): adults >=18 years; BMI >=30 OR BMI >=27 with >=1 comorbidity; trial of behavioral modification >=3 months; dose limited to 15 mg once weekly; quantity limited to 4 prefilled pens or single-dose vials per 28 days or 1 Kwikpen/multi-dose vial per 28 days; not used concurrently with other weight-loss medications; for OSA: sleep study within 12 months with AHI >=15 and exclusions for central sleep apnea; re-authorization: >=5% baseline weight loss after 7 months for chronic weight management; for OSA: >=10% weight loss after 12 months and stability in OSA symptoms.
- Wegovy (semaglutide) injection/tablets: adults (and pediatrics >=12 for some indications) per labeling; adjunct to reduced-calorie diet and increased physical activity; injection adult maintenance dosing and quantity limits differ by formulation (injection: dose limited to 7.2 mg once weekly; quantity limited to 4 pens per 28 days for some formulations; tablets: 25 mg daily with 30 tablets/30 days); not used concurrently with other weight-loss medications; re-authorization: >=5% baseline body weight loss after 7 months for chronic weight management; MACE indication has product-specific criteria including BMI >=27 and established CVD; re-authorization durations differ (up to 12 months for MACE indication).
- Contrave (naltrexone/bupropion): adults per labeling; initial authorization example 4 months; re-authorization may be 1 year when clinical benefit (>=5% baseline body weight after 15 weeks) and continued adherence to diet/activity.
- Liraglutide products (Saxenda, generic liraglutide): adults and pediatrics per labeling; initial approvals/lengths vary (e.g., 4 months); re-authorization requires weight loss thresholds (adults >=4% after 16 weeks and tolerating maintenance dose of 3 mg daily; pediatrics >=1% baseline BMI after 16 weeks and tolerating maintenance dose of 2.4 or 3 mg daily) and continued diet/activity.
- Phentermine/topiramate ER (Qsymia and generic): adults (and pediatrics >=12 for some formulations) per labeling; re-authorization examples: >=5% baseline BMI (peds) or body weight (adults) after 26 weeks and continued adherence to diet/activity.
- General: Documentation required for all products includes baseline body weight, BMI, relevant history, dietary and physical activity plans, and medication dosage for reviews; many benefit plans exclude weight-management drugs—verify benefit document.
Product-specific quantity limits and dispensing unit clarifications updated in 2025–2026 (e.g., Wegovy 4 pens/28 days; Zepbound dispensing unit specifics).
inv-10: Evidence-based coverage considerations — clinical trial populations, efficacy endpoints, and safety signals that inform coverage decisions.
Clinical trial evidence and safety considerations that inform coverage decisions (summary):
ALL of the following
- Contrave: efficacy evaluated in COR trials (4 randomized multicenter 56-week trials; N=4,536); co-primary endpoints included percent change in body weight and proportion achieving >=5% weight loss; trials conducted with reduced-calorie diet and increased physical activity (behavioral programs).
- Foundayo: studied in ATTAIN Phase 3 trials (72 weeks) with lifestyle counseling; demonstrated clinically meaningful percent weight change vs placebo across doses (reported -7.5% to -11.2% in ATTAIN-1).
- Qsymia: adult and pediatric randomized trials with titration and 52–56 week outcomes showed statistically significant percent weight loss and higher rates of >=5% weight loss vs placebo.
- Saxenda (liraglutide): three 56-week trials with hypocaloric diet and exercise counseling showed significant weight reduction; safety includes rodent thyroid C-cell tumor signal and contraindication for personal/family history of medullary thyroid carcinoma (MTC) or MEN 2.
- Wegovy (semaglutide): three 68-week trials (and a withdrawal trial) with escalation to 2.4 mg weekly showed significant weight loss across subgroups; SELECT cardiovascular outcomes trial assessed MACE in high cardiovascular-risk individuals (large sample).
Coverage is contingent on use with lifestyle modification as evaluated in trials; safety signals (predominantly gastrointestinal adverse events; thyroid C-cell tumor signal for GLP-1 agents) and age-related safety considerations are noted in product labeling and trial reports.
inv-11: Selected coverage-related statements and clinical findings from document excerpt
Selected recent policy updates and clarifications (summary):
ALL of the following
- 2021: Wegovy (semaglutide) added to policy.
- 2022: Pediatric Qsymia indication added; pediatric re-authorization criteria added; brand orlistat added with identical criteria as Xenical; clarified adult vs pediatric percent-change basis for re-authorization.
- 2025: Expanded list of weight-related comorbid conditions; clarified FDA dosing adherence; non-formulary exception approvals may be granted up to 12 months; added generic product sequencing requirements (e.g., trial of generic phentermine/topiramate ER before Qsymia; trial of generic liraglutide pen before Saxenda).
- 2026: Clarified product-specific quantity limits and acceptable dispensing units for Zepbound and Wegovy (pens/vials/Kwikpen/multi-dose vial distinctions).
History entries document incremental additions (e.g., Zepbound added 2023; MACE indication updates in 2024–2026) and quantity/dose refinements across 2021–2026.
inv-12: History-based coverage changes (summary)
Revision history overview (high-level):
ALL of the following
- Policy first effective 01/01/21 with initial drug coverage criteria for Contrave, Qsymia, Saxenda, and Xenical.
- Subsequent annual and interim reviews (2021–2026) added Wegovy, Zepbound, pediatric indications, step requirements (generic sequencing), re-authorization thresholds, and clarified quantity/dispensing unit limits.
- 2024–2026: added MACE-related indication for Wegovy (injection and tablets) and updated Wegovy HD dosing; refined quantity limits for Wegovy and Zepbound in 2025–2026.
See full policy history for dated entries and specific edits; verify current effective date and last review date when applying criteria.
Coding, Quantity Limits and Dosing Notes
| No specific CPT/HCPCS/ICD-10/NDC codes provided in this excerpt. |
| No coding specified in this document section (N/A listed). |
| No billing or HCPCS/NDC codes present in this document section. |
| Policy specifies quantity limits by product and formulation but does not list billing/coding codes in this excerpt. |
Authorization, Documentation, and Clinical Submission Guidance
Require ≥3-month behavioral/dietary trial before starting therapy
Prior to initiating prescription therapy for chronic weight management, document that the individual has engaged in a trial of behavioral modification and dietary restriction for at least 3 months and that medication will be used as an adjunct to a reduced-calorie diet and increased physical activity.
- At least 3 months of behavioral modification and dietary restriction required prior to drug initiation
- Medication must be adjunctive to reduced-calorie diet and increased physical activity
Step therapy: trial of specified generic required before some brand agents
For selected branded agents (examples cited include Qsymia, Saxenda, and Wegovy), coverage requires documentation of a trial with—or intolerance/inadequate response to—a specified generic alternative prior to approving the brand.
- Qsymia: trial and inadequate response or intolerance to generic phentermine and topiramate ER required
- Saxenda: trial and inadequate response or intolerance to generic liraglutide 18 mg/3 mL pen required
- Wegovy branded sequencing clarified in revision history
Do not use concurrently with other weight‑loss drugs; follow dose/quantity limits
Ensure medications are not prescribed or dispensed for concurrent use with other weight‑loss medications listed in the policy; apply product-specific dose and quantity limits when prescribing.
- Concurrent use with other weight‑loss medications (e.g., Alli, Contrave, Foundayo, Saxenda, Wegovy, Xenical, Zepbound, Qsymia, etc.) is prohibited
- Adhere to drug-specific dose limits (examples in policy include Contrave 4 tablets/day; Wegovy injection dose limits) and quantity limits per timeframe
Request appropriate initial approval lengths and document re-authorization criteria
Follow product-specific initial authorization lengths and re-authorization criteria; submit evidence of required treatment duration and documented weight-loss response per drug.
- Contrave initial authorization may be for 4 months; re-authorization reviews may be approved for 1 year when clinical benefit is demonstrated (e.g., ≥5% baseline weight loss after 15 weeks)
- Liraglutide products (generic and Saxenda) initial approvals may be 4 months with re-authorization criteria (e.g., ≥4% weight loss after 16 weeks and tolerating maintenance dose)
- Wegovy injection for chronic weight management may be approved for 7 months with re-authorization generally requiring ≥5% baseline weight loss after 7 months
Submit medical records and verify benefit coverage
Provide complete medical records and benefit verification to demonstrate medical necessity, including baseline weight, BMI, relevant weight‑related history, dietary and physical activity plans, and current medication dosing.
- Office visit notes must include baseline body weight and BMI
- Include relevant history (weight‑related comorbidities), dietary plan, physical activity plan, and medication dosage
- Verify benefit plan coverage as weight‑management drugs may be excluded under some plans and contact customer service if needed
Concurrent therapy with other listed weight‑loss drugs is prohibited
Do not initiate or continue treatment concurrently with any other weight‑loss medication listed in the policy (multiple examples provided); ensure prior‑therapy sequencing requirements (e.g., trials of specific generics) are met instead of concurrent use.
- Policy lists specific prohibited concurrent agents (e.g., Alli, benzphetamine, Contrave, diethylpropion, Foundayo, liraglutide pen, phentermine, Qsymia, Saxenda, Wegovy, Xenical, Zepbound)
- Where sequencing is required, document trial/intolerance of the required prior agent rather than combining therapies
Provide Contrave trial context and lifestyle‑intervention evidence with requests
When requesting coverage for Contrave, include evidence reflecting the trial populations and enrollment criteria from the Contrave trials (e.g., use with reduced‑calorie diet and increased physical activity) to support medical necessity.
- Contrave trials (COR studies) evaluated Contrave with reduced‑calorie diet and behavioral counseling; treatment initiation included a dose‑escalation period and instruction to take with food
- Document that the patient meets age, BMI, comorbidity, and behavioral‑trial criteria consistent with the trials
Document Foundayo dosing arms and required lifestyle counseling from trials
For Foundayo (orforglipron) requests, document the trial dosing regimen and that lifestyle counseling was provided; note that pivotal ATTAIN trials tested 6, 12, and 36 mg (reported as 5.5, 9, 17.2 mg in PI) and excluded individuals with type 2 diabetes in ATTAIN‑1.
- ATTAIN‑1 randomized individuals to Foundayo 6, 12, or 36 mg (doses elsewhere referred to as 5.5, 9, or 17.2 mg) with lifestyle counseling and titration over weeks
- ATTAIN‑1 excluded individuals with T2DM; ATTAIN‑2 included individuals with T2DM—note which trial population aligns with the patient
Include Qsymia titration and response details and prior‑therapy trial evidence
For Qsymia submissions, include titration schedule and evidence of response consistent with the trials (adult 52‑week or pediatric 56‑week data); document prior lifestyle intervention and trial of generic phentermine/topiramate ER where required.
- Trials included a 4‑week titration period followed by 52 weeks (adults) or 56 weeks (pediatrics) with primary efficacy at ~1 year
- Document that the patient completed prior lifestyle intervention and, if required, tried generic phentermine/topiramate ER with inadequate response or intolerance
Document Saxenda lifestyle run‑in and screen for thyroid/MEN2 history
When requesting Saxenda, document that the patient received a hypocaloric diet and exercise counseling as in trials; include safety‑relevant history—specifically any personal or family history of medullary thyroid carcinoma (MTC) or MEN 2 given the boxed warning.
- Saxenda trials included a hypocaloric diet (~500 kcal/day deficit) and exercise counseling (≥150 min/week) beginning with first dose
- Saxenda has a boxed warning for rodent thyroid C‑cell tumors and is contraindicated in individuals with personal or family history of MTC or MEN 2
Document Wegovy dose escalation, lifestyle intervention, and MACE criteria when applicable
For Wegovy requests, include documentation of dose escalation to maintenance (up to 2.4 mg weekly for standard indication or up to 7.2 mg weekly for Wegovy HD where specified), lifestyle intervention counseling, and—if for cardiovascular risk reduction—evidence meeting SELECT trial‑style criteria (age, BMI, established CVD and optimized CVD therapy).
- Wegovy pivotal trials escalated dose to 2.4 mg weekly during a 16‑ to 20‑week period with concomitant reduced‑calorie diet and increased physical activity counseling
- SELECT trial evaluated MACE outcomes in adults ≥45 years with BMI >27 and established cardiovascular disease; MACE indication has specific baseline and therapeutic optimization requirements
- Policy history notes addition of Wegovy HD and dose limit updates (2.4 mg to 7.2 mg weekly) in recent revisions
Follow revised quantity limits and acceptable dispensing units per policy updates
Adhere to updated product quantity limits and acceptable dispensing units as specified in policy updates: e.g., Wegovy injection quantity limited to 4 pens per 28 days; Zepbound quantity limited to 4 prefilled pens or single‑dose vials per 30 days or 1 Kwikpen/multi‑dose vial per 28 days.
- Wegovy injection: 4 pens per 28 days (policy clarification 2026)
- Zepbound: 4 prefilled pens or single‑dose vials per 30 days, or 1 Kwikpen or multi‑dose vial per 28 days (2026 update)
- Earlier 2025 language referenced 4 pens/vials per 30 days for these products
Document prior‑therapy trials for exceptions; non‑formulary exceptions may be up to 12 months
When seeking non‑formulary exceptions or prior‑therapy exceptions, document prior trials as required; note that non‑formulary exception authorizations may be approved up to 12 months per the 2025 update.
- Provide documentation of trials of generics or formulary alternatives when required (e.g., generic phentermine/topiramate ER before Qsymia; generic liraglutide before Saxenda)
- Non‑formulary exception approvals may be authorized for up to 12 months
Ensure prior‑authorization submissions document required trials and sequencing to avoid denial
Prior authorization history shows many products required prior authorization and sequencing trials; ensure submitted records demonstrate required prior trials and meet policy criteria to avoid denial.
- Policy history documents updates requiring trials of generic alternatives before branded agents and application of quantity limits
- Include proof of prior trial completion, intolerance, or inadequate response where sequencing is mandated
Key Terms and Trial Definitions
Policy Revision Timeline
Added Wegovy HD and updated Wegovy injection dose limit to 7.2 mg once weekly; added Foundayo (orforglipron) coverage criteria for adults; updated multiple product criteria (Contrave, generic liraglutide, generic phentermine-topiramate ER, Qsymia, Saxenda).
Updated Zepbound (tirzepatide) quantity limit language to 4 prefilled pens or single‑dose vials per 30 days (refined dispensing unit definitions).
Added Wegovy tablets indication for reduction of MACE and chronic weight management and updated Wegovy injection criteria; clarified Zepbound quantity limits and added Wegovy tablets criteria.
Interim review approved January 13, 2026 (recorded 02/01/26) reflecting product additions and quantity-limit clarifications earlier in 2026.
Interim review approved July 8, 2025 expanded adult weight-related comorbidity list and allowed non-formulary exception authorizations up to 12 months; subsequently added generic product sequencing in 2025.
Interim updates clarified step therapy requirements (trial with generic phentermine/topiramate ER) and required trial with generic liraglutide before Saxenda; adjusted quantity limits for Wegovy, generic liraglutide, and Zepbound in late 2025/early 2026.
Updated Wegovy coverage criteria to include certain individuals with established cardiovascular disease (MACE indication).
Added coverage criteria for Zepbound (tirzepatide).
Minor pediatric quantity limit correction for Wegovy and other minor corrections to pediatric language.
Added pediatric coverage for Qsymia and brand orlistat (identical to Xenical) and standardized re-authorization language specifying adult weight loss percent from baseline body weight and pediatric percent from baseline BMI; shortened pediatric behavioral modification trial to 3 months for some drugs (interim Feb 14, 2023 further shortened to 3 months).
New policy effective January 1, 2021 (approved December 8, 2020) adding coverage criteria for Contrave, Qsymia, Saxenda, and Xenical for chronic weight management; Wegovy added August 2021.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.