{
  "name": "GLP-1 Insurance Denial Trigger Crosswalk",
  "version": "1.0",
  "last_verified": "2026-08-03",
  "publisher": "Weight Loss Provider Guide Research",
  "unit_of_analysis": "One exact policy instance, not one insurer brand",
  "scope": "Publicly posted 2026 policy instances with an adult chronic-weight-management pathway",
  "definitions": {
    "denial_trigger": "A published policy condition that can block initial approval or continuation when unmet; not a measured denial frequency.",
    "not_stated": "The rule was not stated in the exact reviewed pathway; it does not mean another plan document cannot impose it.",
    "fixed_prior_lifestyle_months": "A numeric value only when the reviewed policy expressly states a pre-drug period.",
    "previous_medication_sequence_status": "Explicit only when the reviewed pathway expressly requires a medication sequence before the requested therapy; otherwise Not stated.",
    "policy_document_reports_denial_rate": "True only if the policy document itself reports a denominator-based denial rate or denial-reason share."
  },
  "trigger_codebook": {
    "D1": {
      "name": "Benefit or contract exclusion",
      "definition": "The applicable plan does not include the weight-management drug benefit, so clinical criteria cannot create coverage."
    },
    "D2": {
      "name": "Product, formulary, or indication mismatch",
      "definition": "The requested drug, formulation, diagnosis, or use does not fit the covered pathway."
    },
    "D3": {
      "name": "Age, BMI, or comorbidity mismatch",
      "definition": "The request does not satisfy the policy's demographic or clinical entry route."
    },
    "D4": {
      "name": "Lifestyle or medication prerequisite unmet",
      "definition": "A required program, behavioral period, previous medication, preferred product, or treatment sequence is missing."
    },
    "D5": {
      "name": "Documentation, submission, or prescriber deficiency",
      "definition": "Required baseline values, chart notes, records, attestations, recent measurements, or an eligible-prescriber condition are absent or unmet."
    },
    "D6": {
      "name": "Quantity or concurrent-therapy conflict",
      "definition": "The request exceeds a quantity rule or conflicts with a policy's combination-therapy restriction."
    },
    "D7": {
      "name": "Continuation criterion unmet",
      "definition": "The patient has not met or documented the response, ongoing-program, benefit, titration, or other renewal condition."
    }
  },
  "derived_findings": {
    "policy_instances": 8,
    "review_pathway_present": 8,
    "lifestyle_condition_present": 8,
    "fixed_prior_lifestyle_period": 4,
    "previous_medication_sequence": 2,
    "continuation_conditions_present": 8,
    "five_percent_wegovy_or_zepbound_continuation_route": 8,
    "adult_entry_bmi_minimum": 25,
    "adult_entry_bmi_maximum": 35,
    "policy_documents_reporting_denial_rate": 0
  },
  "records": [
    {
      "policy_id": "UHC-COMM-2026-P-1114-21",
      "organization": "UnitedHealthcare",
      "policy_instance": "UnitedHealthcare Commercial — plans with weight-loss/appetite-suppression medication coverage",
      "line_of_business": "Commercial",
      "geographic_scope": "United States; member benefit and state mandates can change application",
      "policy_title": "Prior Authorization/Notification — Plans with Weight Loss/Appetite Suppression Medication Coverage",
      "policy_number_version": "2026 P 1114-21",
      "drug_scope": "Weight-loss/appetite-suppression products including Saxenda, Wegovy, and Zepbound",
      "indication_scope": "Adult chronic weight management; other indication pathways also appear",
      "policy_date": "Effective 2026-07-01",
      "last_verified_date": "2026-08-03",
      "review_pathway": "Prior authorization/notification",
      "review_pathway_present": true,
      "benefit_gate": "Optional program used for clients or businesses that elected weight-loss-drug coverage; member benefit and mandates can also control",
      "adult_bmi_only_threshold": 30,
      "adult_bmi_alternate_threshold": 27,
      "alternate_comorbidity_count": 1,
      "conditional_bmi_threshold": "",
      "conditional_bmi_route": "",
      "lifestyle_condition": "Use as an adjunct to lifestyle modification",
      "fixed_prior_lifestyle_months": "",
      "previous_medication_sequence_status": "Not stated",
      "previous_medication_count": "",
      "previous_medication_sequence": "Not stated in the reviewed general adult pathway",
      "documentation_or_other_trigger": "Requested indication, product, age, and applicable benefit must fit the pathway; no separate document-submission rule is stated in the general adult route",
      "concurrent_therapy_rule": "Not stated in the current reviewed general adult pathway",
      "initial_authorization": "Saxenda 4 months; Wegovy 5 months; Zepbound 6 months",
      "continuation_rule": "Saxenda ≥4% loss; Wegovy ≥5%; Zepbound ≥5%; continuation of lifestyle modification; generally 12-month reauthorization",
      "continuation_5pct_for_wegovy_or_zepbound": true,
      "continuation_conditions_present": true,
      "policy_document_reports_denial_rate": false,
      "denial_trigger_codes": "D1;D2;D3;D4;D7",
      "source_url": "https://www.uhcprovider.com/content/dam/provider/docs/public/prior-auth/drugs-pharmacy/commercial/r-z/PA-Notification-Weight-Loss.pdf",
      "source_location": "PDF pp. 1–4, Coverage Criteria and Reauthorization",
      "notes": "The current general pathway does not contain the concurrent-use restriction attributed to it in the draft."
    },
    {
      "policy_id": "AETNA-NONMED-6450-C-P08-2025-V8",
      "organization": "Aetna",
      "policy_instance": "Aetna Non-Medicare Prescription Drug Plan — Weight Loss (BMI 35)",
      "line_of_business": "Non-Medicare prescription drug plan",
      "geographic_scope": "Plan-specific; the bulletin is a partial general description, not a contract",
      "policy_title": "Weight Loss (BMI 35) GIP-GLP-1, GLP-1 Agonists PA with Limit",
      "policy_number_version": "6450-C P08-2025 v8",
      "drug_scope": "Foundayo, Mounjaro, Saxenda, Wegovy, Wegovy HD, and Zepbound as specified",
      "indication_scope": "Adult long-term weight reduction; separate MASH, OSA, cardiovascular, and pediatric pathways",
      "policy_date": "Dated 2026-04-10",
      "last_verified_date": "2026-08-03",
      "review_pathway": "Prior authorization with quantity limit",
      "review_pathway_present": true,
      "benefit_gate": "The bulletin is not a contract and contains only a partial, general description of plan or program benefits",
      "adult_bmi_only_threshold": 35,
      "adult_bmi_alternate_threshold": "",
      "alternate_comorbidity_count": "",
      "conditional_bmi_threshold": "",
      "conditional_bmi_route": "",
      "lifestyle_condition": "Comprehensive program with behavioral modification, reduced-calorie diet, increased activity, and continuing follow-up",
      "fixed_prior_lifestyle_months": 6,
      "previous_medication_sequence_status": "Not stated",
      "previous_medication_count": "",
      "previous_medication_sequence": "Not stated in the reviewed adult long-term weight-reduction pathway",
      "documentation_or_other_trigger": "Baseline BMI documentation is expressly required; product-specific quantity limits apply",
      "concurrent_therapy_rule": "The bulletin repeats product-label statements that coadministration is not recommended; it is not listed as a separate adult weight-coverage criterion",
      "initial_authorization": "Product-specific: Saxenda adult 4 months; Wegovy injection, Wegovy HD, Foundayo, and tirzepatide weight route 8 months; Wegovy tablet 6 months",
      "continuation_rule": "Saxenda: ≥4% after at least 16 weeks; Wegovy, tirzepatide, or Foundayo: ≥5% after at least 3 months at a stable maintenance dose; 12-month continuation",
      "continuation_5pct_for_wegovy_or_zepbound": true,
      "continuation_conditions_present": true,
      "policy_document_reports_denial_rate": false,
      "denial_trigger_codes": "D2;D3;D4;D5;D6;D7",
      "source_url": "https://www.aetna.com/products/rxnonmedicare/data/2026/Weight_Loss_%28BMI%2035%29_GIP-GLP-1%2C_GLP-1_Agonists_PA_with_Limit_6450-C_P08-2025_v8.html",
      "source_location": "Coverage Criteria; Continuation of Therapy; Quantity Limits; Duration of Approval",
      "notes": "Official live HTML was verified directly on the issuing domain."
    },
    {
      "policy_id": "CIGNA-CNF-684-2026",
      "organization": "Cigna",
      "policy_instance": "Cigna National Formulary — Weight Loss GLP-1 Prior Authorization",
      "line_of_business": "Cigna-administered benefit plans using the National Formulary policy",
      "geographic_scope": "Plan-specific; customer benefit document supersedes the policy in a conflict",
      "policy_title": "Weight Loss — Glucagon-Like Peptide-1 Agonists Prior Authorization Policy",
      "policy_number_version": "CNF 684",
      "drug_scope": "Foundayo, liraglutide/Saxenda, Wegovy, Wegovy HD, and Zepbound",
      "indication_scope": "Adult chronic weight management; separate indication and pediatric routes",
      "policy_date": "Reviewed 2025-07-09; selected revisions through 2026-04-15",
      "last_verified_date": "2026-08-03",
      "review_pathway": "Prior authorization",
      "review_pathway_present": true,
      "benefit_gate": "The customer benefit-plan document can contain an exclusion and always supersedes the coverage policy in a conflict",
      "adult_bmi_only_threshold": 30,
      "adult_bmi_alternate_threshold": 27,
      "alternate_comorbidity_count": 1,
      "conditional_bmi_threshold": "",
      "conditional_bmi_route": "",
      "lifestyle_condition": "Behavioral modification and dietary restriction before therapy, followed by ongoing behavioral modification and reduced-calorie diet",
      "fixed_prior_lifestyle_months": 3,
      "previous_medication_sequence_status": "Not stated",
      "previous_medication_count": "",
      "previous_medication_sequence": "Not stated in the reviewed general adult pathway",
      "documentation_or_other_trigger": "Coverage review may use chart notes, tests, claims, prescription records, and other patient-specific evidence",
      "concurrent_therapy_rule": "Concomitant use with another GLP-1 or GLP-1/GIP agonist is listed as not medically necessary",
      "initial_authorization": "Product-specific; Saxenda 4 months and several newer chronic-weight products 8 months",
      "continuation_rule": "Saxenda ≥4% loss; Foundayo, Wegovy, and Zepbound adult weight pathways use ≥5% loss, with continued lifestyle treatment",
      "continuation_5pct_for_wegovy_or_zepbound": true,
      "continuation_conditions_present": true,
      "policy_document_reports_denial_rate": false,
      "denial_trigger_codes": "D1;D2;D3;D4;D5;D6;D7",
      "source_url": "https://static.cigna.com/assets/chcp/pdf/coveragePolicies/cnf/cnf_684_coveragepositioncriteria_weight_loss_glp1_agonists_pa.pdf",
      "source_location": "Adult Weight Loss criteria; Conditions Not Covered; plan-document instructions",
      "notes": "The policy is guidance for benefit administration; the customer plan controls."
    },
    {
      "policy_id": "FEPBLUE-5.99.031-2026",
      "organization": "FEP Blue",
      "policy_instance": "FEP Blue — Zepbound policy",
      "line_of_business": "Federal Employee Program prescription drug policy",
      "geographic_scope": "FEP Blue policy instance",
      "policy_title": "Zepbound",
      "policy_number_version": "5.99.031",
      "drug_scope": "Zepbound",
      "indication_scope": "Adult chronic weight management",
      "policy_date": "Effective 2026-01-01; last reviewed 2025-12-12",
      "last_verified_date": "2026-08-03",
      "review_pathway": "Prior approval / clinical review",
      "review_pathway_present": true,
      "benefit_gate": "Final validation and coverage determination occur after required documentation; preferred-product rules also apply",
      "adult_bmi_only_threshold": 30,
      "adult_bmi_alternate_threshold": 27,
      "alternate_comorbidity_count": 1,
      "conditional_bmi_threshold": "",
      "conditional_bmi_route": "",
      "lifestyle_condition": "Participation in a comprehensive weight-management program",
      "fixed_prior_lifestyle_months": "",
      "previous_medication_sequence_status": "Explicit",
      "previous_medication_count": 2,
      "previous_medication_sequence": "Inadequate response, intolerance, or contraindication to at least two oral weight-management medications",
      "documentation_or_other_trigger": "Medical records or laboratory reports; preferred product unless a medical exception applies",
      "concurrent_therapy_rule": "No dual therapy with another GLP-1 receptor agonist or another prior-authorized weight-loss medication",
      "initial_authorization": "6 months",
      "continuation_rule": "≥5% loss or maintenance of the initial 5% loss, continued program participation, no prohibited dual therapy, and preferred-product rule",
      "continuation_5pct_for_wegovy_or_zepbound": true,
      "continuation_conditions_present": true,
      "policy_document_reports_denial_rate": false,
      "denial_trigger_codes": "D2;D3;D4;D5;D6;D7",
      "source_url": "https://www.fepblue.org/-/media/PDFs/Medical-Policies/2026/January/Pharmacy-Policies/Add-New/599031-Zepbound-tirzepatide.pdf",
      "source_location": "PDF pp. 3–5, Prior-Approval and Renewal Requirements",
      "notes": "The reviewed policy is drug-specific, not a carrier-wide rule for every weight-management product."
    },
    {
      "policy_id": "KPNW-ZEPBOUND-2026-06-18",
      "organization": "Kaiser Permanente Northwest",
      "policy_instance": "Kaiser Permanente Northwest Commercial — non-formulary Zepbound",
      "line_of_business": "Commercial prescription drug benefit",
      "geographic_scope": "Kaiser Foundation Health Plan of the Northwest",
      "policy_title": "Kaiser Permanente Northwest Region Criteria for Coverage — tirzepatide (Zepbound)",
      "policy_number_version": "Criteria-Based Consultation Prescribing Program",
      "drug_scope": "Zepbound",
      "indication_scope": "Adult chronic weight management; separate OSA and diabetes routes",
      "policy_date": "Revised 2026-06-11; effective 2026-06-18",
      "last_verified_date": "2026-08-03",
      "review_pathway": "Non-formulary clinical review",
      "review_pathway_present": true,
      "benefit_gate": "The prescription benefit must cover medications used for weight loss",
      "adult_bmi_only_threshold": 30,
      "adult_bmi_alternate_threshold": 27,
      "alternate_comorbidity_count": 1,
      "conditional_bmi_threshold": "",
      "conditional_bmi_route": "",
      "lifestyle_condition": "Active lifestyle modification or an active behavioral-health referral",
      "fixed_prior_lifestyle_months": "",
      "previous_medication_sequence_status": "Explicit",
      "previous_medication_count": 2,
      "previous_medication_sequence": "Adequate 3-month trials of at least two listed therapies, then a minimum 6-month semaglutide trial and bariatric-medicine chart review, unless an exception applies",
      "documentation_or_other_trigger": "Current weight and BMI documented within approximately 30 days at initiation; chart review after the semaglutide sequence",
      "concurrent_therapy_rule": "Not stated in the reviewed chronic-weight pathway",
      "initial_authorization": "12 months",
      "continuation_rule": "Updated weight and BMI recently documented and ≥5% weight loss achieved and maintained; 12-month continuation",
      "continuation_5pct_for_wegovy_or_zepbound": true,
      "continuation_conditions_present": true,
      "policy_document_reports_denial_rate": false,
      "denial_trigger_codes": "D1;D2;D3;D4;D5;D7",
      "source_url": "https://healthy.kaiserpermanente.org/content/dam/kporg/final/documents/formularies/nw/kp-criteria-zepbound-nw-en-commercial.pdf",
      "source_location": "PDF pp. 1–2 and 7, chronic weight initiation and continued-use criteria",
      "notes": "The approximately 30-day measurement rule is an initiation rule; continuation says recently documented."
    },
    {
      "policy_id": "HCSC-PRIME-WEIGHT-MGMT-2026-06-15-V2",
      "organization": "Health Care Service Corporation / Prime Therapeutics",
      "policy_instance": "HCSC Commercial — Weight Management PA with Quantity Limit",
      "line_of_business": "Commercial plans administered under the program summary",
      "geographic_scope": "Named HCSC Blue Cross plans; approval length varies by plan type",
      "policy_title": "Weight Management Prior Authorization with Quantity Limit Program Summary",
      "policy_number_version": "HCSC Commercial CS, 2026-06-15 v2",
      "drug_scope": "Foundayo, Saxenda, Wegovy, and Zepbound",
      "indication_scope": "Adult chronic weight management; separate OSA, MASH, and cardiovascular routes",
      "policy_date": "Effective 2026-06-15",
      "last_verified_date": "2026-08-03",
      "review_pathway": "Prior authorization with quantity limit",
      "review_pathway_present": true,
      "benefit_gate": "Application and initial approval length vary by the named HCSC plan type",
      "adult_bmi_only_threshold": 30,
      "adult_bmi_alternate_threshold": 27,
      "alternate_comorbidity_count": 1,
      "conditional_bmi_threshold": 25,
      "conditional_bmi_route": "Pretreatment BMI ≥25 for a patient of South Asian, Southeast Asian, or East Asian descent",
      "lifestyle_condition": "Inadequate response to low-calorie diet, increased activity, and behavioral modification before therapy; regimen continues during treatment",
      "fixed_prior_lifestyle_months": 6,
      "previous_medication_sequence_status": "Not stated",
      "previous_medication_count": "",
      "previous_medication_sequence": "Not stated in the reviewed chronic-weight pathway",
      "documentation_or_other_trigger": "Drug, indication, age, plan type, and FDA-labeled contraindications must fit the route",
      "concurrent_therapy_rule": "No combination with another weight-loss agent or another GLP-1 receptor agonist",
      "initial_authorization": "Some named plans: 12 months; all other plans: Foundayo/Wegovy/Zepbound 12 months, adult Saxenda 4 months, pediatric Saxenda 5 months",
      "continuation_rule": "Adult Saxenda ≥4%; Wegovy, Foundayo, or Zepbound ≥5% or specified time-based route; continued regimen; no prohibited combination; 12-month renewal",
      "continuation_5pct_for_wegovy_or_zepbound": true,
      "continuation_conditions_present": true,
      "policy_document_reports_denial_rate": false,
      "denial_trigger_codes": "D2;D3;D4;D6;D7",
      "source_url": "https://www.myprime.com/content/dam/prime/memberportal/forms/AuthorForms/HCSC/Program_Summaries/HCSC_Weight_Management_ProgSum.pdf",
      "source_location": "PDF pp. 14–17, chronic weight route, approval length, and renewal evaluation",
      "notes": "The BMI-25 route is conditional and must not be generalized beyond this policy instance."
    },
    {
      "policy_id": "MEDMUTUAL-WEIGHT-GLP1-2026-01-15",
      "organization": "Medical Mutual of Ohio",
      "policy_instance": "Medical Mutual of Ohio — Weight Loss GLP-1 Agonists",
      "line_of_business": "Plans with a weight-loss-drug benefit",
      "geographic_scope": "Plan-specific; many plans exclude weight-loss drugs",
      "policy_title": "Weight Loss Glucagon-Like Peptide-1 (GLP1) Agonists",
      "policy_number_version": "Prescription drug policy; last revised 2026-01-15",
      "drug_scope": "Generic liraglutide, Saxenda, Wegovy, and Zepbound",
      "indication_scope": "Adult chronic weight management; separate pediatric and indication routes",
      "policy_date": "Last revised 2026-01-15",
      "last_verified_date": "2026-08-03",
      "review_pathway": "Prior authorization",
      "review_pathway_present": true,
      "benefit_gate": "Prior authorization is available only for members whose plan covers weight-loss drugs; the policy says many plans exclude them",
      "adult_bmi_only_threshold": 32,
      "adult_bmi_alternate_threshold": 27,
      "alternate_comorbidity_count": 2,
      "conditional_bmi_threshold": "",
      "conditional_bmi_route": "",
      "lifestyle_condition": "Behavioral modification and dietary restriction before therapy, followed by ongoing behavioral modification and reduced-calorie diet",
      "fixed_prior_lifestyle_months": 3,
      "previous_medication_sequence_status": "Not stated",
      "previous_medication_count": "",
      "previous_medication_sequence": "Not stated in the reviewed adult chronic-weight pathway",
      "documentation_or_other_trigger": "Baseline BMI/weight documentation and an eligible prescriber pathway; specified specialties are excluded from the route",
      "concurrent_therapy_rule": "Coverage is not recommended with another FDA-approved weight-loss drug or another GLP-1/GLP-1-GIP agonist",
      "initial_authorization": "Saxenda 4 months; Wegovy up to 7 months; Zepbound up to 1 year",
      "continuation_rule": "Adult Saxenda ≥4%; Wegovy and Zepbound ≥5%; continued behavioral modification and reduced-calorie diet; extended approval up to 1 year",
      "continuation_5pct_for_wegovy_or_zepbound": true,
      "continuation_conditions_present": true,
      "policy_document_reports_denial_rate": false,
      "denial_trigger_codes": "D1;D2;D3;D4;D5;D6;D7",
      "source_url": "https://www.medmutual.com/-/media/MedMutual/Files/Providers/Prior-Auth-Rx/Weight-Loss-GlucagonLike-Peptide1-GLP1-Agonists.pdf",
      "source_location": "PDF pp. 1–8, authorization criteria, approval duration, and Conditions Not Recommended for Approval",
      "notes": "The prescriber-specialty rule is specific to this policy instance."
    },
    {
      "policy_id": "REGENCE-DRU787-V5-2026-07-15",
      "organization": "Regence / Cambia",
      "policy_instance": "Regence — GLP-1 Agonist-Containing Medications for Non-Diabetic Indications",
      "line_of_business": "Medication policy; benefit contract controls",
      "geographic_scope": "Applicable Regence contracts using policy dru787",
      "policy_title": "GLP-1 Agonist-Containing Medications for Non-Diabetic Indications",
      "policy_number_version": "dru787; document version dru787.5",
      "drug_scope": "Liraglutide/Saxenda, Wegovy/Wegovy HD, and Zepbound",
      "indication_scope": "Adult chronic weight management; separate cardiovascular, MASH, OSA, pediatric, and continuation routes",
      "policy_date": "Committee approved 2026-06-04; effective 2026-07-15",
      "last_verified_date": "2026-08-03",
      "review_pathway": "Medication policy / preauthorization pathway",
      "review_pathway_present": true,
      "benefit_gate": "Contract language controls; coverage cannot be approved when the benefit contract excludes obesity or overweight treatment",
      "adult_bmi_only_threshold": 30,
      "adult_bmi_alternate_threshold": 27,
      "alternate_comorbidity_count": 1,
      "conditional_bmi_threshold": "",
      "conditional_bmi_route": "",
      "lifestyle_condition": "Attestation that the medication will be used with lifestyle modification",
      "fixed_prior_lifestyle_months": "",
      "previous_medication_sequence_status": "Not stated",
      "previous_medication_count": "",
      "previous_medication_sequence": "Not stated in the reviewed adult chronic-weight pathway",
      "documentation_or_other_trigger": "Clinical documentation and product-specific quantity limits; benefit contract remains controlling",
      "concurrent_therapy_rule": "Coadministration of medications for obesity or overweight is considered investigational and not covered",
      "initial_authorization": "Authorization is reviewed at least annually; product-specific quantity limits apply",
      "continuation_rule": "At least annual review; adult chronic-weight route requires ≥5% loss from pretreatment baseline or current upward dose titration, plus benefit coverage and lifestyle attestation",
      "continuation_5pct_for_wegovy_or_zepbound": true,
      "continuation_conditions_present": true,
      "policy_document_reports_denial_rate": false,
      "denial_trigger_codes": "D1;D2;D3;D4;D5;D6;D7",
      "source_url": "https://regence.myprime.com/content/dam/prime/memberportal/forms/AuthorForms/Cambia/Program_Summaries/dru787reg.pdf",
      "source_location": "PDF pp. 1–5 and Investigational Uses, benefit administration, new-start, annual review, and coadministration sections",
      "notes": "The alternative continuation route is active upward dose titration, not an automatic waiver of review."
    }
  ]
}