GLP-1 medications can play an important role in supporting eligible Members with weight management as part of a broader care plan. MVP is committed to helping Providers navigate coverage requirements, formulary guidelines, and medical policy criteria so appropriate requests can be reviewed as efficiently as possible. By confirming coverage before prescribing and submitting complete prior authorization (PA) information, Providers can help set realistic expectations for patients, reduce delays, and support timely access to care for their patients.

Coverage varies by plan

GLP-1 medications used for weight loss may be considered for coverage when the applicable plan includes the benefit, and the request meets all policy criteria. Coverage may vary across New York State Commercial plans, and certain Self-Funded groups. Providers should verify benefit coverage, formulary requirements, and any exclusions before submitting a PA request.

Submit complete documentation for new start requests

For new start requests, chart notes should include current BMI, height, and weight; documentation that lifestyle changes were tried for at least six months before the request; and evidence of active participation for at least six months in a qualifying Plan Approved Weight Loss Program. Missing or incomplete documentation may delay review or result in a PA denial.

What qualifies as a plan approved weight loss program?

A qualifying program must show active, verifiable participation and include nutrition management, physical activity, behavior modification, and counseling, coaching, or other structured support. Programs may be offered in person, online, or virtually if they meet all required components.

Programs that only include calorie counting, step tracking, exercise, or unverified self-directed activity do not meet the requirements when they lack all required components or proof of participation.

Continuation requests

For continuation requests, documentation must support continued eligibility, including a BMI of 25 or greater, at least 5% initial body weight loss, compliance with maintenance-dose requirements, and continued participation in qualifying lifestyle medicine supports when required by policy.

Requests for other medically accepted indications

When a GLP-1 medication is prescribed for another medically accepted indication, such as cardiovascular risk reduction or sleep apnea, MVP reviews the request using indication-specific criteria. Weight loss program enrollment may not be required for those indication-specific reviews.

Provider talking points

When discussing GLP-1 weight loss medication requests, Providers may want to explain that authorization review is based on current MVP medical policy criteria and requires documentation that supports the applicable diagnosis, weight loss history, lifestyle program participation, and other clinical requirements. For other medically accepted indications, requests are reviewed using the criteria specific to that indication.

Provider reminders

Before submission, confirm that documentation clearly supports the applicable criteria, including the individualized weight loss plan, ongoing engagement, and physical activity details when activity occurs outside structured visits. Appeals, peer-to-peer reviews, and reconsiderations are evaluated using the criteria in effect at the time of review.

Before submitting a request, review the MVP Medical Policy for Weight Loss Medications and confirm plan-specific coverage requirements.

You can also direct members to view the GLP-1 Medications for Weight Loss page for more information.

Providers should review information and talking points with their patients about GLP-1 Medications and Weight Loss Coverage. Review information and talking points.