Specialty Pharmacy Clinical Policy Bulletins Aetna Non-Medicare Prescription Drug Plan
Subject: Weight Loss (BMI 35) GIP-GLP-1, GLP-1 Agonists PA with Limit 6450-C P08-2025 v8
Drug
Weight Loss (BMI 35) GIP-GLP-1, GLP-1 Agonists
FOUNDAYO(orforglipron)
MOUNJARO(tirzepatide)
SAXENDA(liraglutide)
WEGOVY(semaglutide)
WEGOVY HD(semaglutide)
ZEPBOUND(tirzepatide)
Note: Drugs that are listed in the following table include both brand and generic and all dosage forms and strengths except Zepbound vials and Zepbound Kwikpens, which are covered under the LillyDirect manufacturer program. Over-the-counter (OTC) products are not included unless otherwise stated.
Policy:
Indications
FDA-approved Indications
Foundayo
Foundayo is indicated in combination with a reduced-calorie diet and increased physical activity to reduce excess body weight and maintain weight reduction long term in adults with obesity or adults with overweight in the presence of at least one weight-related comorbid condition.
Limitations of Use
Concomitant use with another GLP-1 receptor agonist is not recommended.
Saxenda
Saxenda is indicated in combination with a reduced calorie diet and increased physical activity to reduce excess body weight and maintain weight reduction long term in:
Adult and pediatric patients aged 12 years and older with body weight greater than 60 kg and obesity
Adults with overweight in the presence of at least one weight-related comorbid condition.
Limitations of Use
Saxenda contains liraglutide. Coadministration with other liraglutide-containing products or with any other glucagon-like peptide-1 (GLP-1) receptor agonist is not recommended.
The safety and effectiveness of Saxenda in pediatric patients with type 2 diabetes have not been established.
Wegovy
Wegovy injection is indicated in combination with a reduced calorie diet and increased physical activity:
To reduce the risk of major adverse cardiovascular (CV) events (CV death, non-fatal myocardial infarction, or non-fatal stroke) in adults with established CV disease and either obesity or overweight.
To reduce excess body weight and maintain weight reduction long term in:
Adults and pediatric patients aged 12 years and older with obesity.
Adults with overweight in the presence of at least one weight-related comorbid condition.
For the treatment of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH), formerly known as nonalcoholic steatohepatitis (NASH), with moderate to advanced liver fibrosis (consistent with stages F2 to F3 fibrosis) in adults. This indication is approved under accelerated approval based on improvement of MASH and fibrosis. Continued approval for this indication may be contingent upon the verification and description of clinical benefit in a confirmatory trial.
Wegovy tablets are indicated in combination with a reduced calorie diet and increased physical activity:
To reduce the risk of major adverse CV events (CV death, non-fatal myocardial infarction, or non-fatal stroke) in adults with established CV disease and either obesity or overweight.
To reduce excess body weight and maintain weight reduction long term in adults with obesity, or in adults with overweight in the presence of at least one weight-related comorbid condition.
Limitations of Use
Concomitant use of Wegovy (semaglutide) tablets or Wegovy (semaglutide) injection with other semaglutide-containing products or with any other GLP-1 receptor agonist is not recommended.
Tirzepatide (Zepbound/Mounjaro)
Zepbound is indicated in combination with a reduced-calorie diet and increased physical activity:
to reduce excess body weight and maintain weight reduction long term in adults with obesity or adults with overweight in the presence of at least one weight-related comorbid condition.
to treat moderate to severe obstructive sleep apnea (OSA) in adults with obesity.
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.
Mounjaro is indicated as an adjunct to diet and exercise to improve glycemic control in adults and pediatric patients 10 years of age and older with type 2 diabetes mellitus.
Coverage Criteria
Noncirrhotic Metabolic Dysfunction-Associated Steatohepatitis (Adult) – Wegovy Injection ONLY (EXCLUDING Wegovy HD 7.2 mg Injection)
Authorization may be granted when the requested drug is being prescribed for the treatment of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH), formerly known as nonalcoholic steatohepatitis (NASH), with moderate to advanced liver fibrosis (consistent with stages F2 to F3 fibrosis) in an adult when ALL of the following criteria are met:
The request is for Wegovy (semaglutide).
The request is NOT for Wegovy (semaglutide) HD 7.2 mg injection OR Wegovy (semaglutide) tablets.
The requested drug is being used with a reduced-calorie diet AND increased physical activity.
The requested drug is being prescribed by, or in consultation with, a gastroenterologist or hepatologist.
The patient’s moderate to advanced liver fibrosis (consistent with stages F2 to F3 fibrosis) at baseline has been confirmed by ONE of the following: non-invasive liver disease assessment (e.g., ultrasound-based elastography, magnetic resonance elastography [MRE]) OR historical liver biopsy. [ACTION REQUIRED: Documentation is required for approval.]
Reduction in Excess Body Weight, Maintenance of Weight Reduction Long Term (Adult)
Authorization may be granted when the requested drug will be used with a reduced-calorie diet AND increased physical activity to reduce excess body weight or maintain weight reduction long term when ALL of the following criteria are met:
The patient is 18 years of age or older.
The patient has participated in a comprehensive weight management program that encourages behavioral modification, reduced-calorie diet, AND increased physical activity with continuing follow-up for at least 6 months prior to using drug therapy.
The patient has a baseline body mass index (BMI) greater than or equal to 35 kg/m2. [NOTE: If the patient is transitioning from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy.] [ACTION REQUIRED: Documentation is required for approval.]
Reduction in Excess Body Weight, Maintenance of Weight Reduction Long Term (Pediatric) – Saxenda and Wegovy Injection ONLY (EXCLUDING Wegovy HD 7.2 mg Injection)
Authorization may be granted when the requested drug will be used with a reduced-calorie diet AND increased physical activity to reduce excess body weight or maintain weight reduction long term when ALL of the following criteria are met:
The patient is 12 to 17 years of age.
The patient has participated in a comprehensive weight management program that encourages behavioral modification, reduced-calorie diet, AND increased physical activity with continuing follow-up for at least 6 months prior to using drug therapy.
If the request is for Saxenda (liraglutide), then ALL of the following criteria are met:
The patient has a body weight above 60 kg. [NOTE: If the patient is transitioning from another drug therapy for weight loss, please consider their baseline body weight at the start of any drug therapy.] [ACTION REQUIRED: Documentation is required for approval.]
The patient has a baseline body mass index (BMI) corresponding to 30 kg/m2 or greater for adults by international cut-offs based on the Cole Criteria. [NOTE: If the patient is transitioning from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy.] [ACTION REQUIRED: Documentation is required for approval.]
If the request is for Wegovy (semaglutide), then ALL of the following criteria are met:
The request is NOT for Wegovy (semaglutide) HD 7.2 mg injection OR Wegovy (semaglutide) tablets.
The patient has a baseline BMI in the 95th percentile or greater standardized for age and sex (obesity). [NOTE: If the patient is transitioning from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy.] [ACTION REQUIRED: Documentation is required for approval.]
Obstructive Sleep Apnea (Adult) – Tirzepatide (Zepbound/Mounjaro) ONLY
Authorization may be granted when the requested drug will be used with a reduced-calorie diet AND increased physical activity to treat moderate to severe obstructive sleep apnea (OSA) in an adult with obesity when ALL of the following criteria are met:
The request is for tirzepatide (Zepbound/Mounjaro).
The patient has an established diagnosis of moderate to severe OSA with an apnea-hypopnea index (AHI) of at least 15 events per hour on polysomnography (PSG) or home sleep apnea test (HSAT) with a technically adequate device. [ACTION REQUIRED: Documentation is required for approval.]
The patient has a current body mass index (BMI) greater than or equal to 30 kg/m2. [ACTION REQUIRED: Documentation is required for approval.]
Risk Reduction of Major Adverse Cardiovascular Events (Adult) – Wegovy ONLY (EXCLUDING Wegovy HD 7.2 mg Injection)
Authorization may be granted when the requested drug will be used to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction (MI), or non-fatal stroke) in an adult with established cardiovascular disease AND either obesity or overweight when ALL of the following criteria are met:
The request is for Wegovy (semaglutide).
The request is NOT for Wegovy (semaglutide) HD 7.2 mg injection.
The requested drug is being used with a reduced-calorie diet AND increased physical activity.
The patient has established cardiovascular disease with a history of ONE of the following: [ACTION REQUIRED: Documentation is required for approval.]
Previous MI.
Previous stroke.
Symptomatic peripheral arterial disease (PAD), as evidenced by intermittent claudication with ankle-brachial index (ABI) less than 0.85 (at rest), peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease.
Prior history of revascularization (coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or angioplasty).
The patient has a baseline body mass index (BMI) greater than or equal to 27 kg/m2. [NOTE: If the patient is transitioning from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy.] [ACTION REQUIRED: Documentation is required for approval.]
The patient does NOT have type 2 diabetes. [NOTE: Ozempic is indicated to reduce the risk of major cardiovascular events in adults with type 2 diabetes mellitus and established cardiovascular disease. Patients with type 2 diabetes may be treated for risk reduction of cardiovascular events with Ozempic.]
The patient is currently receiving guideline-directed management and therapy (GDMT) for cardiovascular disease (e.g., lipid-lowering agent, antiplatelet, beta-blocker, renin-angiotensin inhibitor, etc.) OR the patient has a clinical reason not to be treated with GDMT for cardiovascular disease. [ACTION REQUIRED: Documentation is required for approval.]
Continuation of Therapy
Noncirrhotic Metabolic Dysfunction-Associated Steatohepatitis (Adult) – Wegovy Injection ONLY (EXCLUDING Wegovy HD 7.2 mg Injection)
Authorization may be granted when the requested drug is being prescribed for the treatment of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH), formerly known as nonalcoholic steatohepatitis (NASH), with moderate to advanced liver fibrosis (consistent with stages F2 to F3 fibrosis) in an adult when ALL of the following criteria are met:
The request is for Wegovy (semaglutide).
The request is NOT for Wegovy (semaglutide) HD 7.2 mg injection OR Wegovy (semaglutide) tablets.
The requested drug is being used with a reduced-calorie diet AND increased physical activity.
The patient has achieved or maintained a positive clinical response to the requested drug (e.g., improvement in liver function such as reduction in alanine aminotransferase [ALT], improvement in Enhanced Liver Fibrosis [ELF] score, improvement in liver stiffness measurement [LSM] by ultrasound-based elastography, magnetic resonance elastography [MRE]). [ACTION REQUIRED: Documentation is required for approval.]
The patient is being treated with a maintenance dosage of the requested drug which is based on individual treatment response and tolerability.
Reduction in Excess Body Weight, Maintenance of Weight Reduction Long Term (Adult)
Authorization may be granted when the requested drug will be used with a reduced-calorie diet AND increased physical activity to reduce excess body weight or maintain weight reduction long term when ALL of the following criteria are met:
The patient is 18 years of age or older.
The patient had a baseline body mass index (BMI) greater than or equal to 35 kg/m2 at the start of drug therapy for weight loss. [NOTE: If the patient transitioned from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy.] [ACTION REQUIRED: Documentation is required for approval.]
If the request is for Saxenda (liraglutide), then ALL of the following criteria are met:
The patient has completed at least 16 weeks of therapy with the requested drug.
The patient has lost at least 4 percent of baseline body weight OR the patient has continued to maintain their initial 4 percent weight loss. [ACTION REQUIRED: Documentation is required for approval.]
If the request is for Wegovy (semaglutide), tirzepatide (Zepbound/Mounjaro), or Foundayo (orforglipron), then ALL of the following criteria are met:
The patient has completed at least 3 months of therapy with the requested drug at a stable maintenance dose.
The patient has lost at least 5 percent of baseline body weight OR the patient has continued to maintain their initial 5 percent weight loss. [ACTION REQUIRED: Documentation is required for approval.]
Reduction in Excess Body Weight, Maintenance of Weight Reduction Long Term (Pediatric) – Saxenda and Wegovy Injection ONLY (EXCLUDING Wegovy HD 7.2 mg Injection)
Authorization may be granted when the requested drug will be used with a reduced-calorie diet AND increased physical activity to reduce excess body weight or maintain weight reduction long term when ALL of the following criteria are met:
The patient is 12 to 17 years of age.
If the request is for Saxenda (liraglutide), then ALL of the following criteria are met:
The patient had a baseline body mass index (BMI) corresponding to 30 kg/m2 or greater for adults by international cut-offs based on the Cole Criteria at the start of drug therapy for weight loss. [NOTE: If the patient transitioned from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy.] [ACTION REQUIRED: Documentation is required for approval.]
The patient has completed at least 12 weeks of therapy on the maintenance dose of the requested drug.
The patient has had at least 1 percent reduction in BMI from baseline OR the patient has continued to maintain their initial 1 percent BMI reduction. [ACTION REQUIRED: Documentation is required for approval.]
If the request is for Wegovy (semaglutide), then ALL of the following criteria are met:
The request is NOT for Wegovy (semaglutide) HD 7.2 mg injection OR Wegovy (semaglutide) tablets.
The patient had a baseline BMI in the 95th percentile or greater standardized for age and sex (obesity) at the start of drug therapy for weight loss. [NOTE: If the patient transitioned from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy.] [ACTION REQUIRED: Documentation is required for approval.]
The patient has successfully titrated to a stable maintenance dose.
The patient has had a reduction from their baseline BMI OR the patient has continued to maintain their initial BMI reduction. [ACTION REQUIRED: Documentation is required for approval.]
Obstructive Sleep Apnea (Adult) – Tirzepatide (Zepbound/Mounjaro) ONLY
Authorization may be granted when the requested drug will be used with a reduced-calorie diet AND increased physical activity to treat moderate to severe obstructive sleep apnea (OSA) in an adult with obesity when ALL of the following criteria are met:
The request is for tirzepatide (Zepbound/Mounjaro).
The patient has an established diagnosis of moderate to severe OSA with an apnea-hypopnea index (AHI) of at least 15 events per hour on polysomnography (PSG) or home sleep apnea test (HSAT) with a technically adequate device. [ACTION REQUIRED: Documentation is required for approval.]
The patient has achieved or maintained a positive response to treatment from baseline, evidenced by a decrease in OSA symptoms.
The patient is being treated with a maintenance dosage of the requested drug which is based on individual treatment response and tolerability.
Risk Reduction of Major Adverse Cardiovascular Events (Adult) – Wegovy ONLY (EXCLUDING Wegovy HD 7.2 mg Injection)
Authorization may be granted when the requested drug will be used to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction (MI), or non-fatal stroke) in an adult with established cardiovascular disease AND either obesity or overweight when ALL of the following criteria are met:
The request is for Wegovy (semaglutide).
The request is NOT for Wegovy (semaglutide) HD 7.2 mg injection.
The requested drug is being used with a reduced-calorie diet AND increased physical activity.
The patient has established cardiovascular disease with a history of ONE of the following: [ACTION REQUIRED: Documentation is required for approval.]
Previous MI.
Previous stroke.
Symptomatic peripheral arterial disease (PAD), as evidenced by intermittent claudication with ankle-brachial index (ABI) less than 0.85 (at rest), peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease.
Prior history of revascularization (coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or angioplasty).
The patient is being treated with a maintenance dosage of the requested drug which is based on individual treatment response and tolerability.
Quantity Limits Apply
The duration of 21 days is used for a 28-day fill period and 63 days is used for an 84-day fill period to allow time for refill processing.
The duration of 25 days is used for a 30-day fill period and 75 days is used for a 90-day fill period to allow time for refill processing.
Drug
Dosage
1 Month Limit
3 Month Limit
Foundayo (orforglipron)
0.8 mg, 2.5 mg, 5.5 mg, 9 mg, 14.5 mg, 17.2 mg
30 tablets / 25 days
90 tablets / 75 days
Saxenda (liraglutide)
18 mg / 3 mL (provides variable dosing)
15 mL (1 package of five 3 mL pens) / 25 days
45 mL (3 packages of five 3 mL pens each) / 75 days
Reduction in excess body weight, maintenance of weight reduction long term in patients 18 years of age and older: Initial therapy DOA: 8 months; Continuation of therapy DOA: 12 months
Wegovy (semaglutide) Injection:
Reduction in excess body weight, maintenance of weight reduction long term in patients 18 years of age and older: Initial therapy DOA: 8 months; Continuation of therapy DOA: 12 months
Reduction in excess body weight, maintenance of weight reduction long term in patients 12 to 17 years of age: Initial therapy DOA: 7 months; Continuation of therapy DOA: 12 months
Reduction in excess body weight, maintenance of weight reduction long term: Initial therapy DOA: 8 months; Continuation of therapy DOA: 12 months
Place of Service:
Outpatient
The above policy is based on the following references:
Foundayo [package insert]. Indianapolis, IN: Lilly USA, LLC; April 2026.
Saxenda [package insert]. Plainsboro, NJ: Novo Nordisk Inc.; May 2025.
Wegovy [package insert]. Plainsboro, NJ: Novo Nordisk Inc.; March 2026.
Zepbound [package insert]. Indianapolis, IN: Lilly USA, LLC; January 2026.
Mounjaro [package insert]. Indianapolis, IN: Lilly USA, LLC; January 2026.
Lexicomp Online, AHFS DI (Adult and Pediatric) Online. Waltham, MA: UpToDate, Inc.; 2026. https://online.lexi.com. Accessed April 1, 2026.
Micromedex® (electronic version). Merative, Ann Arbor, Michigan, USA. Available at: https://www.micromedexsolutions.com (cited: 04/01/2026).
Jensen MD, Ryan DH, Apovian DM, et al. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Obesity Society. Circulation. 2014;129(suppl 2):S102-S138.
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):342–362.
US Preventive Services Task Force. Interventions for High Body Mass Index in Children and Adolescents US Preventive Services Task Force Recommendation Statement. JAMA. 2024;Online ahead of print. doi: 10.1001/jama.2024.11146.
Lincoff AM, Brown-Frandsen K, Colhoun HM, et al. Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes. N Engl J Med. 2023;389:2221-2232.
Virani SS, Newby LK, Arnold SV, et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2023;148:e9-e119.
Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2021;52(7):e364-e467.
Gornik HL, Aronow HD, Goodney PP, et al. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2024;83(24):2497-2604.
Malhorta A, Grunstein RR, Fietze I, et al. Tirzepatide for the Treatment of Obstructive Sleep Apnea and Obesity. New Engl J Med. 2024;391:1193-1205.
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. J Clin Sleep Med. 2017;13(3):479-504.
Sanyal AJ, Newsome PN, Kliers I, et al. Phase 3 Trial of Semaglutide in Metabolic Dysfunction-Associated Steatohepatitis. New Engl J Med. 2025;392:2089-2099.
Chen VL, Morgan TR, Rotman Y, et al. Resmetirom therapy for metabolic dysfunction-associated steatotic liver disease: October 2024 updates to AASLD Practice Guidance. Hepatology. 2025;81(1):312-320.
Rinella ME, Neuschwander-Tetri BA, Siddiqui MS, et al. AASLD Practice Guidance on the clinical assessment and management of nonalcoholic fatty liver disease. Hepatology 2023;77(5): 1797-1835.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
