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Table 82: Health Safety Net Formulary Exceptions

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Drug Category: Health Safety Net Formulary Exceptions

Medication Class/Individual Agents: Health Safety Net Formulary Exceptions

I. Prior-Authorization Requirements

 Health Safety Net Formulary Exceptions – Anti-Obesity Agents
Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

Clinical Notes
semaglutide injection-Wegovy for Health Safety Net Wegovy PA   HSNE

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

Please note: anti-obesity agents and/or drugs used for the treatment of obesity are not payable for Health Safety Net patients for weight loss. Wegovy and Zepbound may still be payable for other medically accepted indications. 

Wegovy

  • Documentation of the following is required:
    • diagnosis of risk reduction of major adverse cardiovascular events in patients with established cardiovascular disease and obesity or overweight; and
    • patient is  ≥ 18 years of age; and
    • prescriber is a cardiologist or consult notes from a cardiologist are provided; and
    • patient weight (dated within the 90 days prior to initiation of pharmacotherapy for obesity [does not have to be the requested agent]); and
    • patient BMI is ≥ 27 kg/m2 (dated within the 90 days prior to initiation of pharmacotherapy for obesity [does not have to be the requested agent]); and
    • attestation that the patient does not have any of the following:
      • type 1 diabetes mellitus; or
      • type 2 diabetes mellitus; or
      • New York Heart Association class IV heart failure; and
    • patient has been counseled to continue reduced-calorie diet and increased physical activity; and
    • requested agent will not be used in combination with another GLP-1 receptor agonist; and
    • requested quantity is ≤ four pens/28 days; and
    • medical records documenting patient is receiving all clinically appropriate therapies for management of cardiovascular disease, adverse reaction, or contraindication to the following:
      • for history of myocardial infarction:
        • antiplatelet; and
        • ACE-I or ARB; and
        • beta blocker; and
        • statin; or
      • for history of ischemic stroke:
        • antiplatelet or anticoagulant; and
        • blood pressure management regimen; and
        • statin; or
      • for history of hemorrhagic stroke:
        • blood pressure management regimen; or
        • for symptomatic peripheral artery disease:
        • antiplatelet; and
        • blood pressure management regimen; and
        • statin.
  • For recertification, documentation of the following is required:
    • patient weight (dated within the last 90 days); and
    • patient requires Wegovy for cardiovascular protection and the benefit of cardiovascular protection outweighs the risk associated with the use of GLP-1 agents; and
    • patient has been counseled to continue with reduced-calorie diet and increased physical activity; and
    • one of the following:
      • patient continues to receive appropriate therapies for management of cardiovascular disease; or
      • adverse reaction or contraindication to clinically appropriate therapies for management of cardiovascular disease.

 

Zepbound

  • Documentation of the following is required:
    • diagnosis of moderate to severe obstructive sleep apnea (OSA) in obesity; and
    • patient is ≥ 18 years of age; and
    • prescriber is a neurologist, pulmonologist, or sleep specialist or consult notes from a neurologist, pulmonologist, or sleep specialist are provided; and
    • medical records of the sleep study used to diagnose OSA (polysomnogram); and
    • medical records documenting apnea-hypopnea index (AHI) ≥15 events/hour; and
    • patient weight (dated within the 90 days prior to initiation of pharmacotherapy for obesity [does not have to be the requested agent]); and
    • patient BMI is ≥ 30 kg/m2 (dated within the 90 days prior to initiation of pharmacotherapy for obesity [does not have to be the requested agent]); and
    • attestation that the patient does not have any of the following:
      • type 1 diabetes mellitus; or
      • type 2 diabetes mellitus; or
      • central or mixed sleep apnea; or
      • obesity hypoventilation syndrome or daytime hypercapnia; or
      • major craniofacial abnormalities; or
      • planned procedure for sleep apnea or obesity; and
    • patient has been counseled to continue reduced-calorie diet and increased physical activity; and
    • requested quantity is ≤ four pens/28 days; and
    • requested agent will not be used in combination with another GLP-1 receptor agonist.

 

  • For recertification, documentation of the following is required:
    • patient weight (dated within the last 90 days); and
    • improvement in OSA symptoms, such as less daytime sleepiness, fewer sleep arousals, or fewer partner-reported snoring episodes or pauses in breathing; and
    • patient has been counseled to continue with reduced-calorie diet and increased physical activity.

 

GLP-1 and GIP/GLP-1 Agonist Polypharmacy

  • Documentation of the following is required:
    • individual drug prior authorization criteria must be met first where applicable; and
    • patient is transitioning from one GLP-1 or GIP/GLP-1 agonist to another, and prior GLP-1 or GIP/GLP-1 agonist use will be discontinued.

 

 
tirzepatide-Zepbound for Health Safety Net Zepbound PA   HSNE
Table Footnotes
HSNE This product is not payable under Health Safety Net for weight loss.
 

II. Therapeutic Uses

FDA-approved, for example:

  • Moderate to severe OSA in obesity – Zepbound
  • Risk reduction of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in patients with established cardiovascular disease and obesity or overweight – Wegovy

Note: The above lists may not include all FDA-approved and non-FDA-approved indications.

 

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III.  Evaluation Criteria for Approval

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

  • All PA requests must include clinical diagnosis, drug name, dose, and frequency.
  • Dispensing in a 90-day supply of medication may be mandated or allowable for agents in this therapeutic class (designated by M90 or A90, respectively, in the Drug Notes section above). Applicable quantity limits are described below as units per day, per month, per 28 days, or as clinically appropriate, and may be extrapolated for fills of longer day supply. 
  • A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
  • For recertification requests, approval may require submission of additional documentation including, but not limited to, documentation of: some or all criteria for the original approval; response to therapy; clinical rationale for continuation of use; status of patient’s condition; appropriate diagnosis; appropriate age; appropriate dose, frequency, and duration of use for requested medication; complete treatment plan; current laboratory values; and patient’s current weight.
  • Additional criteria may apply depending upon diagnosis and/or requested medication (see below). Other factors, including rebate and FDA-approval status, may change independently of scheduled MassHealth updates, which may result in additional restrictions.

Please see clinical criteria for agents requiring PA in the table above under the Clinical Notes section.

 

Original Effective Date: 05/2025

Last Revised Date: 05/2025

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Last updated 12/01/25

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