Pharmacy Prior Authorization Criteria

Wegovy (semaglutide) and Zepbound (tirzepatide) – PA, NF

Indications for Prior Authorization

Wegovy (semaglutide)

For diagnosis of Chronic Weight Management
Indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial BMI of 30 kg/m(2) or greater (obesity), or 27 kg/m(2) or greater (overweight) in the presence of at least one weight-related comorbid condition (eg, hypertension, type 2 diabetes mellitus, or dyslipidemia).
For diagnosis of Chronic Weight Management
Indicated as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in pediatric patients aged 12 years and older with an initial BMI at the 95th percentile or greater for age and sex (obesity).
For diagnosis of Reduce the risk of major adverse cardiovascular events
Indicated in combination with a reduced calorie diet and increased physical activity to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in adults with established cardiovascular disease and either obesity or overweight.
For diagnosis of Limitations of Use:
Wegovy contains semaglutide and should not be coadministered with other semaglutide-containing products or with any other GLP-1 receptor agonist. The safety and effectiveness of Wegovy in combination with other products intended for weight loss, including prescription drugs, over-the-counter drugs, and herbal preparations, have not been established. Wegovy has not been studied in patients with a history of pancreatitis.

Zepbound (tirzepatide) Injection

For diagnosis of Chronic Weight Management
Indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial BMI of 30 kg/m(2) or greater (obesity), or 27 kg/m(2) or greater (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, dyslipidemia, type 2 diabetes mellitus, obstructive sleep apnea, or cardiovascular disease).
For diagnosis of Limitations of Use:
Zepbound contains tirzepatide. Coadministration with other tirzepatide-containing products or with any glucagon-like peptide-1 (GLP-1) receptor agonist is not recommended. The safety and efficacy of Zepbound in combination with other products intended for weight management, including prescription drugs, over-the-counter drugs, and herbal preparations, have not been established. Zepbound has not been studied in patients with a history of pancreatitis.
For diagnosis of Obstructive sleep apnea
indicated in combination with a reduced calorie diet and increased physical activity for the treatment of moderate to severe obstructive sleep apnea in adults with obesity.

Criteria

Wegovy*,**

*Please consult client-specific resources to confirm whether benefit exclusions should be reviewed for medical necessity. **If being used for any indication other than appetite suppression/weight loss or to reduce the risk of major adverse cardiovascular events, deny the case for medical necessity and do not review for off-label use.

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Weight Management

Treatment is for weight loss

AND

One of the following:

Both of the following:

Patient is 18 years of age or older
Baseline BMI greater than or equal to 30 kg/m2 prior to initiating any GLP-1 therapy

All of the following:

Patient is 18 years of age or older
Baseline BMI is greater than or equal to 27 kg/m2 prior to initiating any GLP-1 therapy
Patient has a weight-related comorbidity (e.g., hypercholesterolemia, hypertension, diabetes, sleep apnea)

Both of the following:

Patient is between 12 and 17 years of age
Baseline BMI is in the 95th percentile or greater standardized for age and sex prior to initiating any GLP-1 therapy

AND

Medication is not being co-administered with another GLP-1 receptor agonists (e.g., Saxenda, Trulicity, Victoza)

Wegovy

*Baseline BMI refers to patient’s BMI prior to initiating any GLP-1 therapy.

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Weight Management

Treatment is for weight loss

AND

One of the following:

Patient continues to experience or maintain weight loss
Weight loss of greater than or equal to 5% of baseline body weight*

AND

Medication is not being co-administered with another GLP-1 receptor agonists (e.g., Saxenda, Trulicity, Victoza)

Wegovy*,**

Non Formulary (Initial Authorization)

Length of Approval: 6 Month(s) [D]
For diagnosis of Weight Management in Pediatric Patients between 12 and 17 years of age

Treatment is being requested for appetite suppression or weight loss

AND

Patient is between 12 and 17 years of age

AND

Submission of medical records (e.g., chart notes) confirming initial BMI is in the 95th percentile or greater standardized for age and sex prior to initiating any GLP-1 therapy

AND

Used as an adjunct to lifestyle modification (e.g., dietary or caloric restriction, exercise, behavioral support, community based program)

AND

Submission of medical records (e.g., chart notes) or absence of paid claims within the past 90 days confirming medication is not being co-administered with any of the following:

Tirzepatide-containing products (e.g., Mounjaro)
GLP-1 receptor agonists (e.g., Saxenda, Trulicity, Victoza)

AND

Prescribed by a Healthcare Professional knowledgeable about the use of GLP-1s for chronic weight management who will be overseeing the treatment and monitoring of the patient

AND

Medication is not prescribed by the following practitioners:

Chiropractor
Physical therapist
Ophthalmologist
Social Worker
Nurse Midwife
Dentist
Acupuncturist
Audiologist
Fitness Trainer
Anesthesiologist
Counselor
Dermatologist
Registered Dietician
Therapist
Pathologist
Podiatrist
Urologist

Wegovy

*baseline BMI refers to patient’s BMI prior to initiating any GLP-1 therapy.

Non Formulary (Reauthorization)

Length of Approval: 6 Month(s)
For diagnosis of Weight Management in Pediatric Patients between 12 and 17 years of age

Patient is between 12 and 17 years of age

AND

Submission of medical records (e.g., chart notes) confirming weight loss of greater than or equal to 5% of baseline body weight* [B]

AND

Submission of medical records (e.g., chart notes) or absence of paid claims within the past 90 days confirming medication is not being co-administered with any of the following:

Tirzepatide-containing products (e.g., Mounjaro)
GLP-1 receptor agonists (e.g., Saxenda, Trulicity, Victoza)

AND

Prescribed by a Healthcare Professional knowledgeable about the use of GLP-1s for chronic weight management who will be overseeing the treatment and monitoring of the patient

AND

Medication is not prescribed by the following practitioners:

Chiropractor
Physical therapist
Ophthalmologist
Social Worker
Nurse Midwife
Dentist
Acupuncturist
Audiologist
Fitness Trainer
Anesthesiologist
Counselor
Dermatologist
Registered Dietician
Therapist
Pathologist
Podiatrist
Urologist

Wegovy*,**

Non Formulary (Initial Authorization)

Length of Approval: 6 Month(s) [D]
For diagnosis of Weight Management in Adult Patients 18 years of age and older

Treatment is being requested for appetite suppression or weight loss

AND

Patient is 18 years of age or older

AND

Patient must have one or more of the following cardiovascular-related comorbidities [E]:

Hypercholesterolemia
Hypertension
Type 2 diabetes mellitus
Obstructive sleep apnea
Cardiovascular disease

AND

Drug is not being used for Type 2 diabetes mellitus [Note: if patient has T2DM, please consider choosing a GLP-1 receptor agonist that is indicated for the treatment of T2DM (e.g., Ozempic, Rybelsus, Victoza)

AND

Patient's baseline weight and BMI prior to initiating any GLP-1 therapy is provided

AND

Submission of medical records (e.g., chart notes) documenting baseline BMI greater than or equal to 35 kg/m2 prior to initiating any GLP-1 therapy [6]

AND

Submission of medical records (e.g., chart notes) documenting both of the following:

Trial of lifestyle modification that promotes a reduced calorie diet and exercise of at least 150 minutes per week for at least 6 months and patient has failed to achieve adequate weight loss
Patient will be using Wegovy with continued lifestyle modification that promotes a reduced calorie diet and exercise of at least 150 minutes per week

AND

Submission of medical records (e.g., chart notes) or absence of paid claims within the past 90 days confirming medication is not being co-administered with any of the following:

GLP-1 receptor agonists (e.g., Ozempic, Saxenda, Trulicity, Victoza)
Tirzepatide-containing product (e.g., Mounjaro)
Other weight loss agents indicated for short-term weight reduction or chronic weight management (e.g., Phentermine)

AND

One of the following:

Patient is not currently on any drug(s) that may contribute to weight gain (e.g., neuropathic pain medications [gabapentin], antipsychotic medications [olanzapine], corticosteroids, hormonal therapy [estrogen replacement therapy])

Provider attests to both of the following:

Patient is on drugs that may contribute to weight gain
Dose will be lowered or drug will be discontinued, if clinically appropriate

AND

One of the following:

Paid claims or submission of medical records (e.g., chart notes) documenting at least a 3 month trial and inadequate response, contraindication, or intolerance to two non-GLP-1 receptor agonist weight loss medications (e.g., phentermine, Qsymia)
No formulary alternative is available to treat the patient's condition

AND

Prescribed by a Healthcare Professional knowledgeable about the use of GLP-1s for chronic weight management who will be overseeing the treatment and monitoring of the patient

AND

Medication is not prescribed by the following practitioners:

Chiropractor
Physical therapist
Ophthalmologist
Social Worker
Nurse Midwife
Dentist
Acupuncturist
Audiologist
Fitness Trainer
Anesthesiologist
Counselor
Dermatologist
Registered Dietician
Therapist
Pathologist
Podiatrist
Urologist

Wegovy

^PA clinician to confirm weight loss using the patient's baseline and current weight. Baseline BMI refers to patient’s BMI prior to initiating any GLP-1 therapy.

Non Formulary (Reauthorization)

Length of Approval: 6 Month(s)
For diagnosis of Weight Management in Adult Patients 18 years of age and older

Patient is 18 years of age or older

AND

Paid claims or submission of medical records (e.g., chart notes) documenting both of the following:

Patient has been adherent to 4 consecutive months of treatment

AND

One of the following:

Patient is currently on a maintenance dose of 1.7mg or 2.4mg once weekly
Patient has received less than 6 months of treatment with Wegovy and is continuing to titrate to a target dose of 1.7mg or 2.4mg once weekly

AND

Patient's baseline and current weight and BMI is provided

AND

One of the following:

Both of the following:

Patient has received up to 6 months of treatment
Weight loss of greater than or equal to 5% of baseline body weight as confirmed by patient’s current weight and baseline weight^ [B]

Both of the following:

Patient has received greater than 6 months of treatment
Patient is continuing to experience or maintain weight loss as confirmed by patient’s current weight and baseline weight^

AND

Submission of medical records (e.g., chart notes) documenting that patient will be using Wegovy with continued lifestyle modification that promotes a reduced calorie diet and exercise of at least 150 minutes per week

AND

Submission of medical records (e.g., chart notes) or absence of paid claims within the past 90 days confirming medication is not being co-administered with any of the following:

GLP-1 receptor agonists (e.g., Ozempic, Saxenda, Trulicity, Victoza)
Tirzepatide-containing product (e.g., Mounjaro)
Other weight loss agents indicated for short-term weight reduction or chronic weight management (e.g., Phentermine)

AND

One of the following:

Patient is not currently on any drug(s) that may contribute to weight gain (e.g., neuropathic pain medications [gabapentin], antipsychotic medications [olanzapine], corticosteroids, hormonal therapy [estrogen replacement therapy])

Provider attests to both of the following:

Patient is on drugs that may contribute to weight gain
Dose will be lowered or drug will be discontinued, if clinically appropriate

AND

Prescribed by a Healthcare Professional knowledgeable about the use of GLP-1s for chronic weight management who will be overseeing the treatment and monitoring of the patient

AND

Medication is not prescribed by the following practitioners:

Chiropractor
Physical therapist
Ophthalmologist
Social Worker
Nurse Midwife
Dentist
Acupuncturist
Audiologist
Fitness Trainer
Anesthesiologist
Counselor
Dermatologist
Registered Dietician
Therapist
Pathologist
Podiatrist
Urologist

Wegovy*

*If being used for any indication other than appetite suppression/weight loss or to reduce the risk of major adverse cardiovascular events, deny the case for medical necessity and do not review for off-label use.

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Reduce the risk of major adverse cardiovascular events

Treatment is being requested to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke)

AND

Patient is 18 years of age or older

AND

Patient has established cardiovascular disease as evidenced by one of the following [7]:

Prior myocardial infarction (MI)
Prior stroke (i.e., transient ischemic attack, ischemic or hemorrhagic stroke)
Peripheral arterial disease (i.e., intermittent claudication with ankle-brachial index < 0.85, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease)

AND

Used in as an adjunct to lifestyle modification (e.g., dietary or caloric restriction, exercise, behavioral support, community-based program)

AND

BMI greater than or equal to 27 kg/m2

AND

Medication is not being co-administered with any of the following:

GLP-1 receptor agonists (e.g., Victoza, Ozempic, Rybelsus, Trulicity)
Tirzepatide-containing products (e.g., Mounjaro)

Wegovy

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Reduce the risk of major adverse cardiovascular events

Patient is currently on a maintenance dose of 1.7mg or 2.4mg once weekly

AND

Used in as an adjunct to lifestyle modification (e.g., dietary or caloric restriction, exercise, behavioral support, community-based program)

AND

Medication is not being co-administered with any of the following:

GLP-1 receptor agonists (e.g., Victoza, Ozempic, Rybelsus, Trulicity)
Tirzepatide-containing products (e.g., Mounjaro)

Wegovy*

Non Formulary (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Reduce the risk of major adverse cardiovascular events

Treatment is being requested to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke)

AND

Patient is 45 years of age or older

AND

Submission of medical records (e.g., chart notes) documenting patient has established cardiovascular disease as evidenced by one of the following:

Prior myocardial infarction (MI)
Prior stroke (i.e., transient ischemic attack, ischemic or hemorrhagic stroke)
Peripheral arterial disease (i.e., intermittent claudication with ankle-brachial index < 0.85, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease)

AND

Submission of medical records (e.g., chart notes) documenting that medication is being used in combination with a program supporting a reduced calorie diet of at least 500 kcal/day and patient can be active for at least 150 minutes per week

AND

Submission of medical records (e.g., chart notes) documenting BMI greater than or equal to 27 kg/m2

AND

Submission of medical records (e.g., chart notes) documenting HbA1c less than 6.5% in the past 12 months

AND

Submission of medical records (e.g., chart notes) documenting patient does not have any of the following [7]:

Diagnosis of type 1 or type 2 diabetes (excluding gestational diabetes)
NY Heart Association functional class IV heart failure

AND

Submission of medical records (e.g., chart notes) or absence of paid claims confirming medication is not being co-administered with any of the following:

GLP-1 receptor agonists (e.g., Victoza, Ozempic, Rybelsus, Trulicity)
Tirzepatide-containing products (e.g., Mounjaro)

Wegovy

Non Formulary (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Reduce the risk of major adverse cardiovascular events

Submission of medical records (e.g., chart notes) documenting that patient demonstrated medication adherence (e.g., 80% adherence to treatment) over prior 6 months

AND

Submission of medical records (e.g., chart notes) documenting that medication is being used in combination with a program supporting a reduced calorie diet of at least 500 kcal/day and patient can be active for at least 150 minutes per week

AND

Paid claims or submission of medical records (e.g., chart notes) documenting patient is receiving a dose of 1.7mg or 2.4mg per week

AND

Submission of medical records (e.g., chart notes) documenting HbA1c less than 6.5% in the past 12 months

AND

Submission of medical records (e.g., chart notes) documenting patient does not have any of the following:

Diagnosis of type 1 or type 2 diabetes (excluding gestational diabetes)
NY Heart Association functional class IV heart failure

AND

Submission of medical records (e.g., chart notes) or absence of paid claims confirming medication is not being co-administered with any of the following:

GLP-1 receptor agonists (e.g., Victoza, Ozempic, Rybelsus, Trulicity)
Tirzepatide-containing products (e.g., Mounjaro)

Zepbound Pen*,**

*Please consult client-specific resources to confirm whether benefit exclusions should be reviewed for medical necessity. **If being used for any indication other than appetite suppression/weight loss or obstructive sleep apnea, deny the case for medical necessity and do not review for off-label use. ^Baseline BMI refers to patient's BMI prior to initiating any GLP-1 therapy.

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Weight Management

Treatment is for weight loss

AND

One of the following:

Both of the following:

Patient is 18 years of age or older
Baseline BMI greater than or equal to 30 kg/m2 prior to initiating any GLP-1 therapy^

All of the following:

Patient is 18 years of age or older
Baseline BMI is greater than or equal to 27 kg/m2 prior to initiating any GLP-1 therapy
Patient has a weight-related comorbidity (e.g., hypercholesterolemia, hypertension, diabetes, sleep apnea)

AND

Medication is not being co-administered with another GLP-1 receptor agonists (e.g., Saxenda, Trulicity, Victoza)

Zepbound Pen

*Baseline BMI refers to patient's BMI prior to initiating any GLP-1 therapy.

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Weight Management

Treatment is for weight loss

AND

One of the following:

Patient continues to experience or maintain weight loss
Weight loss of greater than or equal to 5% of baseline body weight*

AND

Medication is not being co-administered with another GLP-1 receptor agonists (e.g., Saxenda, Trulicity, Victoza)

Zepbound Pen*,**

*Please consult client-specific resources to confirm whether benefit exclusions should be reviewed for medical necessity. **If being used for any indication other than appetite suppression/weight loss or obstructive sleep apnea, deny the case for medical necessity and do not review for off-label use. ***Shortage of drug is not a reason for bypass of trial requirement.

Non Formulary (Initial Authorization)

Length of Approval: 6 Month(s)
For diagnosis of Weight Management

Treatment is being requested for appetite suppression or weight loss

AND

Patient is 18 years of age or older

AND

Patient must have one or more of the following cardiovascular-related comorbidities [E]:

Hypercholesterolemia
Hypertension
Type 2 diabetes mellitus
Obstructive sleep apnea
Cardiovascular disease

AND

Drug is not being used for Type 2 diabetes mellitus [Note: if patient has T2DM, please consider choosing a GLP-1 receptor agonist that is indicated for the treatment of T2DM (e.g., Ozempic, Rybelsus, Victoza, Mounjaro)

AND

Patient's baseline weight and BMI prior to initiating any GLP-1 therapy is provided

AND

Submission of medical records (e.g., chart notes) documenting a BMI greater than or equal to 35 kg/m2 prior to initiating any GLP-1 therapy [6]

AND

Submission of medical records (e.g., chart notes) documenting both of the following:

Trial of lifestyle modification that promotes a reduced calorie diet and exercise of at least 150 minutes per week for at least 6 months and patient has failed to achieve adequate weight loss
Patient will be using Zepbound with continued lifestyle modification that promotes a reduced calorie diet and exercise of at least 150 minutes per week

AND

Submission of medical records (e.g., chart notes) or absence of paid claims within the past 90 days confirming medication is not being co-administered with any of the following:

GLP-1 receptor agonists (e.g., Ozempic, Saxenda, Trulicity, Victoza)
Tirzepatide-containing product (e.g., Mounjaro)
Other weight loss agents indicated for short-term weight reduction or chronic weight management (e.g., Phentermine)

AND

One of the following:

Patient is not currently on any drug(s) that may contribute to weight gain (e.g., neuropathic pain medications [gabapentin], antipsychotic medications [olanzapine], corticosteroids, hormonal therapy [estrogen replacement therapy])

Provider attests to both of the following:

Patient is on drugs that may contribute to weight gain
Dose will be lowered or drug will be discontinued, if clinically appropriate

AND

One of the following:

Paid claims or submission of medical records (e.g., chart notes) documenting at least a 3 month trial and inadequate response, contraindication, or intolerance to two non-GLP-1 receptor agonist weight loss medications (e.g., phentermine, Qsymia)

No formulary alternative is available to treat the patient's condition

AND

Prescribed by a Healthcare Professional knowledgeable about the use of GLP-1s for chronic weight management who will be overseeing the treatment and monitoring of the patient

AND

Medication is not prescribed by the following practitioners:

Chiropractor
Physical Therapist
Ophthalmologist
Social Worker
Nurse Midwife
Dentist
Acupuncturist
Audiologist
Fitness Trainer
Anesthesiologist
Counselor
Dermatologist
Registered Dietician
Therapist
Pathologist
Podiatrist
Urologist

Zepbound Pen

^PA clinician to confirm weight loss using the patient's baseline and current weight. Baseline BMI refers to patient’s BMI prior to initiating any GLP-1 therapy. *Shortage of drug is not a reason for bypass of trial requirement.

Non Formulary (Reauthorization)

Length of Approval: 6 Month(s)
For diagnosis of Weight Management

Paid claims or submission of medical records (e.g., chart notes) documenting both of the following:

Patient has been adherent to 3 consecutive months of treatment
Patient is currently on a maintenance dose of 5mg, 7.5mg, 10mg, 12.5mg or 15mg once weekly

AND

Patient's baseline and current weight and BMI is provided

AND

One of the following:

Both of the following:

Patient has received up to 6 months of treatment
Weight loss of greater than or equal to 5% of baseline body weight as confirmed by patient’s current weight and baseline weight^ [B]

Both of the following:

Patient has received greater than 6 months of treatment
Patient is continuing to experience or maintain weight loss as confirmed by patient’s current weight and baseline weight^

AND

Submission of medical records (e.g., chart notes) documenting that patient will be using Zepbound with continued lifestyle modification that promotes a reduced calorie diet and exercise of at least 150 minutes per week

AND

Submission of medical records (e.g., chart notes) or absence of paid claims within the past 90 days confirming medication is not being co-administered with any of the following:

GLP-1 receptor agonists (e.g., Ozempic, Saxenda, Trulicity, Victoza)
Tirzepatide-containing product (e.g., Mounjaro)
Other weight loss agents indicated for short-term weight reduction or chronic weight management (e.g., Phentermine)

AND

One of the following:

Patient is not currently on any drug(s) that may contribute to weight gain (e.g., neuropathic pain medications [gabapentin], antipsychotic medications [olanzapine], corticosteroids, hormonal therapy [estrogen replacement therapy])

Provider attests to both of the following:

Patient is on drugs that may contribute to weight gain
Dose will be lowered or drug will be discontinued, if clinically appropriate

AND

Prescribed by a Healthcare Professional knowledgeable about the use of GLP-1s for chronic weight management who will be overseeing the treatment and monitoring of the patient

AND

Medication is not prescribed by the following practitioners:

Chiropractor
Physical Therapist
Ophthalmologist
Social Worker
Nurse Midwife
Dentist
Acupuncturist
Audiologist
Fitness Trainer
Anesthesiologist
Counselor
Dermatologist
Registered Dietician
Therapist
Pathologist
Podiatrist
Urologist

Zepbound Pen*

*If being used for any indication other than appetite suppression/weight loss or obstructive sleep apnea, deny the case for medical necessity and do not review for off-label use.

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s)
For diagnosis of Obstructive Sleep Apnea

Diagnosis of obstructive sleep apnea

AND

Disease is moderate to severe as defined by 15 or more obstructive respiratory events (e.g., apnea-hypopnea index [AHI]) per hour of sleep confirmed by a sleep study

AND

Patient is 18 years of age or older

AND

Body Mass Index (BMI) of greater than or equal to 30 kg/m2

AND

One of the following:

Prescriber attests that the patient has been evaluated and counseled on continuous positive airway pressure CPAP therapy as the preferred treatment of choice

Patient is not a candidate for CPAP therapy (e.g., upper airway anatomic abnormalities, etc.)

AND

Used as an adjunct to lifestyle modification (e.g., dietary or caloric restriction, exercise, behavioral support, community based program)

AND

Medication is not being co-administered with any of the following:

Tirzepatide-containing product (e.g., Mounjaro)
GLP-1 receptor agonists (e.g., Saxenda, Trulicity, Victoza)

Zepbound Pen

Prior Authorization (Reauthorization)

Length of Approval: 6 Month(s)
For diagnosis of Obstructive Sleep Apnea

Patient is currently on a maintenance dose of 10 mg, 12.5mg, or 15 mg once weekly

AND

One of the following:

Patient has been receiving Zepbound therapy for up to 6 months and has had a weight loss of greater than or equal to 5% of baseline body weight

Patient has been receiving Zepbound therapy for greater than 6 months and is continuing to experience or maintain weight loss

AND

Used as an adjunct to lifestyle modification (e.g., dietary or caloric restriction, exercise, behavioral support, community based program)

AND

Medication is not being co-administered with any of the following:

Tirzepatide-containing product (e.g., Mounjaro)
GLP-1 receptor agonists (e.g., Saxenda, Trulicity, Victoza)

Zepbound Pen*

*If being used for any indication other than appetite suppression/weight loss or obstructive sleep apnea, deny the case for medical necessity and do not review for off-label use.

Non Formulary (Initial Authorization)

Length of Approval: 6 Month(s)
For diagnosis of Obstructive Sleep Apnea

Diagnosis of obstructive sleep apnea

AND

Submission of medical records (e.g., chart notes) confirming disease is moderate to severe as defined by 15 or more obstructive respiratory events (e.g., apnea-hypopnea index [AHI]) per hour of sleep confirmed by a sleep study [8, 10-11]

AND

Patient is 18 years of age or older

AND

Submission of medical records (e.g., chart notes) confirming Body Mass Index (BMI) of greater than or equal to 30 kg/m2

AND

Submission of medical records (e.g., chart notes) confirming one of the following: [9]

Patient has been evaluated and counseled on continuous positive airway pressure CPAP therapy as the preferred treatment of choice

Patient is not a candidate for CPAP therapy (e.g., upper airway anatomic abnormalities, etc.)

AND

Submission of medical records (e.g., chart notes) confirming medication will be used in combination with a program supporting a reduced calorie diet of at least 500 kcal/day and patient can be active for at least 150 minutes per week

AND

Submission of medical records (e.g., chart notes) confirming HbA1c less than 6.5% in the past 12 months

AND

One of the following:

Paid claims or submission of medical records (e.g., chart notes) confirming at least a 3 month trial and inadequate response, contraindication, or intolerance to one non-GLP-1 receptor agonist weight loss medication (e.g., Qsymia)

No formulary alternative is available to treat the patient's condition

AND

Submission of medical records (e.g., chart notes) or absence of paid claims confirming medication is not being co-administered with any of the following:

Tirzepatide-containing product (e.g., Mounjaro)
GLP-1 receptor agonists (e.g., Saxenda, Trulicity, Victoza)
Other weight loss agents indicated for short-term weight reduction or chronic weight management (e.g., Qsymia)

Zepbound Pen

Non Formulary (Reauthorization)

Length of Approval: 6 Month(s)
For diagnosis of Obstructive Sleep Apnea

Paid claims or submission of medical records (e.g., chart notes) confirming patient is currently on a maintenance dose of 10 mg, 12.5mg, or 15 mg once weekly

AND

One of the following:

Both of the following:

Paid claims or submission of medical records (e.g., chart notes) confirming patient has been receiving Zepbound therapy for up to 6 months
Submission of medical records (e.g., chart notes) confirming weight loss of greater than or equal to 5% of baseline body weight

Both of the following:

Paid claims or submission of medical records (e.g., chart notes) confirming patient has been receiving Zepbound therapy for greater than 6 months
Submission of medical records (e.g., chart notes) confirming patient is continuing to experience or maintain weight loss

AND

Submission of medical records (e.g., chart notes) confirming medication will be used in combination with a program supporting a reduced calorie diet of at least 500 kcal/day and patient can be active for at least 150 minutes per week

AND

Submission of medical records (e.g., chart notes) confirming HbA1c less than 6.5% in the past 12 months

AND

Submission of medical records (e.g., chart notes) or absence of paid claims confirming medication is not being co-administered with any of the following:

Tirzepatide-containing product (e.g., Mounjaro)
GLP-1 receptor agonists (e.g., Saxenda, Trulicity, Victoza)
Other weight loss agents indicated for short-term weight reduction or chronic weight management (e.g., Qsymia)

Zepbound Vial

Prior Authorization and Non Formulary

Requests for Zepbound vials will not be approved as they are not authorized for coverage through pharmacy benefits

Guideline ID
GL-286233
Formulary
premium
Effective date
Jul 1, 2025
P&T approval date

P & T Revisions

2025-06-04, 2025-04-29, 2025-03-05, 2025-01-15, 2024-12-23, 2024-10-18, 2024-10-03, 2024-09-05, 2024-08-02, 2024-06-27, 2024-06-24, 2024-06-03, 2024-05-02, 2024-04-17, 2024-03-22, 2024-03-20, 2024-03-20, 2024-02-19, 2024-02-14, 2024-01-16, 2024-01-12, 2023-12-20, 2023-11-16, 2023-08-01, 2023-06-16, 2023-02-27, 2023-01-31, 2022-11-02, 2022-09-06, 2022-07-21, 2022-06-27, 2022-06-03, 2022-05-06, 2022-02-28, 2021-11-01, 2021-09-01, 2021-08-04, 2021-05-21, 2021-03-03, 2021-02-04, 2020-07-15, 2020-02-19, 2019-10-29, 2019-07-01

References

Saxenda Prescribing Information. Novo Nordisk Inc. Plainsboro, NJ. December 2020.
Apovian CM, Aronne LJ, Bessesen DH, et al. Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2015;100(2): 342-62.
Wegovy Prescribing Information. Novo Nordisk Inc. Plainsboro, NJ. March 2024.
Zepbound Prescribing Information. Lilly USA, LLC Indianapolis, IN. December 2024.
Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism, Volume 100, Issue 2, 1 February 2015, Pages 342–362. https://academic.oup.com/jcem/article/100/2/342/2813109. Accessed May 17, 2022.
Eisenberg D, Shikora SA, Aarts E, et al. 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for Metabolic and Bariatric Surgery. Surg Obes Relat Dis. 2022;18(12):1345-1356.
A. Michael Lincoff, Kirstine Brown‐Frandsen, Colhoun HM, et al. Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes. The New England Journal of Medicine. 2023;389(24). doi:https://doi.org/10.1056/nejmoa2307563
Messineo L, Bakker JP, Cronin J, Yee J, White DP. Obstructive sleep apnea and obesity: a review of epidemiology, pathophysiology and the effect of weight-loss treatments. Sleep Medicine Reviews. Published online August 1, 2024:101996-101996.
Patil SP, Ayappa IA, Caples SM, Kimoff RJ, Patel SR, Harrod CG. Treatment of Adult Obstructive Sleep Apnea with Positive Airway Pressure: An American Academy of Sleep Medicine Clinical Practice Guideline. Journal of Clinical Sleep Medicine. 2019;15(02):335-343.
Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline. Journal of Clinical Sleep Medicine. 2017;13(03):479-504.
Clinical Guideline for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults. Journal of Clinical Sleep Medicine. 2009;05(03):263-276.

End Notes

An adult patient receiving Saxenda should have his/her body weight evaluated at week 16 after initiating therapy. [1]
If a patient's response to a weight loss medication is deemed effective (weight loss greater than or equal to 5% of body weight or BMI) and safe, it is recommended that the medication be continued. [2]
A pediatric patient receiving Saxenda should have his/her BMI evaluated after maintenance dose has been achieved and patient has received 12 weeks of therapy at maintenance dose. [1]
Wegovy has a 7 month approval duration for initial auth, this allows for 16 weeks of dose escalation to reach maintenance dosage and 12 additional weeks of maintenance therapy. The Endocrine Society Clinical Practice Guideline states that 3 months is a reasonable trial period for weight loss medications. [5]
This list includes the most prevalent comorbidities in obesity based on clinical trials and current literature. [1, 2, 3]

Revision History

2025-06-04: New Program
2025-04-29: For Zepbound OSA indication, include apnea hypopnea index [AHI] > or equal to 15 as an example of obstructive respiratory event
2025-03-05: Formatting update to NF criteria Added Zepbound 7.5mg and 10mg vials to criteria
2025-01-15: Update to Zepbound OSA NF criteria; Saxenda, wegovy, and zepbound weight loss criteria updated to clarify that baseline BMI requirement is prior to any GLP-1 therapy.
2024-12-23: Addition of new Zepbound indication of Obstructive Sleep Apnea
2024-10-18: Removal of trial requirement for two non-GLP1s from reauth criteria for Saxenda, Wegovy and Zepbound NF criteria
2024-10-03: Removal of Contrave as example of non-glp1 weight loss agent
2024-09-05: Zepbound vial criteria added to guideline and update to Wegovy initial auth duration to 6 months and updates to any criteria requiring being on Wegovy for 7 months to 6 months
2024-08-02: Added in TIA as an example for stroke for Wegovy CVD indication. Updated Zepbound criteria to remove trial of Saxenda and Wegovy from both initial and reauth.
2024-06-27: Background update
2024-06-24: Obesity GLP1 separate criteria created
2024-06-03: Update to Wegovy NF criteria
2024-05-02: Updated operational note for Wegovy. No changes to criteria.
2024-04-17: Updated Zepbound PA criteria.
2024-03-22: Updated effective date to 3/22/24
2024-03-20: 1) Update Zepbound NF language based on PA ops feedback. No changes to clinical intent, wording updates. 2) Modify Saxenda, Wegovy NF criteria to align with Zepbound NF criteria except for the trial of Saxenda and Wegovy.
2024-03-20: Add in new criteria for Wegovy reduction in MACE indication
2024-02-19: Addition of operational note to Zepbound “Shortage of drug is not a reason for bypass of trial requirement."
2024-02-14: Updates to Zepbound NF criteria and Saxenda/Wegovy PA Criteria
2024-01-16: Updated Zepbound criteria.
2024-01-12: Zepbound PA criteria updated to mirror existing Non Formulary criteria.
2023-12-20: Updated Zepbound Non-Formulary criteria.
2023-11-16: New program for Zepbound
2023-08-01: Added in Wegovy 1.7mg as maintenance therapy option in the NF Reauth criteria
2023-06-16: Updated NF criteria for Wegovy and Saxenda to mirror risk-stratified PA. Separated pediatric and adult indications.
2023-02-27: Annual review - no criteria changes
2023-01-31: Removed generic products including phentermine, phendimetrazine, diethylpropion, diethylpropion ER & benzphetamine as target drugs. Added new criteria for pediatric indication for Wegovy. Consolidated adults/peds criteria for Saxenda to streamline guideline. Updated background and references.
2022-11-02: Added Orlistat to mirror Xenical. Updated references.
2022-09-06: Updated criteria with new indication for Qsymia. Updated background and references.
2022-07-21: Add NF criteria for Saxenda. Also added 90-day lookback duration for absence of paid claims language in NF criteria.
2022-06-27: Updated NF verbiage for Wegovy per PA feedback.
2022-06-03: Added submission of MR/paid claims verbiage to NF sections. Decreased initial auth approval duration to 7 months for Wegovy.
2022-05-06: Added NF criteria for Wegovy.
2022-02-28: Annual Review - no criteria changes
2021-11-01: Updated Saxenda criteria: not to be used in combination with other GLP-1 agonists.
2021-09-01: Removed Brand Regimex as target, now obsolete
2021-08-04: Added Wegovy as new target to guideline.
2021-05-21: Updated guideline name.
2021-03-03: 2021 Annual Review, no changes to criteria.
2021-02-04: Updated Saxenda criteria with expanded indication
2020-07-15: Removed step through Contrave for Qsymia and Saxenda. Contrave now steps through Qsymia.
2020-02-19: 2020 Annual Review: removed Belviq/Belviq XR as targets due to withdrawal from market, updated references. No changes to criteria.
2019-10-29: Added Brand Adipex-P
2019-07-01: Removal of "continuation of lifestyle modification" criteria within the reauth section was approved at May P&T for Saxenda; proceed with updating this for Saxenda only, eff 7/1/19. Evaluate if we should remove this from all drugs in this program for consistency, and if so we can bring these to July P&T. Decision was to remove criteria from guideline…as onust should be on presciber to recommend continuous lifestyle modifications. Also, will remove from Contrave as this is preferred agent, and 7/1 guideline has the non preferred agent, Saxenda, less restrictive until the next update of 8/1 or 9/1

Wegovy (semaglutide) and Zepbound (tirzepatide) – PA, NF

Indications for Prior Authorization

Wegovy (semaglutide)

Zepbound (tirzepatide) Injection

Criteria

Wegovy*,**

Wegovy

Wegovy*,**

Wegovy

Wegovy*,**

Wegovy

Wegovy*

Wegovy

Wegovy*

Wegovy

Zepbound Pen*,**

Zepbound Pen

Zepbound Pen*,**

Zepbound Pen

Zepbound Pen*

Zepbound Pen

Zepbound Pen*

Zepbound Pen

Zepbound Vial

P & T Revisions

References

End Notes

Revision History

Provider Tools