Wegovy — Blue Cross Blue Shield of Illinois

Initial criteria

• ONE of the following:
• A. Diagnosis of obstructive sleep apnea (OSA) [medical records required] AND ALL of:
• 1. Polysomnography (PSG) or home sleep apnea test performed AND
• 2. Apnea hypopnea index (AHI) ≥ 15 events/hour from baseline AND
• 3. Requested agent is Zepbound AND
• 4. Pretreatment BMI ≥ 30 kg/m^2
• OR
• B. Diagnosis of noncirrhotic NASH or MASH [medical records required] AND ALL of:
• 1. Stage F1–F3 fibrosis confirmed by BOTH:
• A. FIB‑4 score consistent with stage F1–F3 adjusted for age AND
• B. ONE of (liver biopsy OR VCTE OR ELF score OR MRE) AND
• 2. Requested agent is Wegovy AND
• 3. Patient age ≥ 18 years AND
• 4. ONE of:
• A. Pretreatment BMI > 25 kg/m^2 OR
• B. Pretreatment BMI > 23 kg/m^2 if South Asian, Southeast Asian, or East Asian descent AND
• 5. Alcohol consumption limits (female <20 g/day OR male <30 g/day) AND
• 6. Being monitored/treated for comorbid conditions AND
• 7. No decompensated cirrhosis, moderate–severe hepatic impairment (Child‑Pugh B or C), or other liver disease AND
• 8. Prescriber is or consulted with hepatologist/gastroenterologist
• OR
• C. Use to reduce risk of major adverse cardiovascular events in adults with established cardiovascular disease and obesity/overweight AND ALL of:
• 1. Requested agent is Wegovy AND
• 2. History of ONE of: myocardial infarction OR stroke OR peripheral artery disease (as defined) AND
• 3. Pretreatment BMI ≥ 27 kg/m^2 AND
• 4. Will use optimized pharmacotherapy for cardiovascular disease with requested agent
• OR
• D. Weight management use AND ALL of:
• 1. Patient new to therapy, new to plan, or attempting repeat weight‑loss course AND
• 2. ONE of:
• A. Adult (age ≥ 18 years) meeting ONE of:
• 1. Pretreatment BMI ≥ 30 kg/m^2 OR
• 2. Pretreatment BMI ≥ 25 kg/m^2 if South/Southeast/East Asian descent OR
• 3. Pretreatment BMI ≥ 27 kg/m^2 with ≥1 weight‑related comorbidity (e.g., hypertension, type 2 diabetes mellitus, OSA, CVD, dyslipidemia)
• B. Pediatric (age 12–17 years) meeting ONE of:
• 1. BMI ≥ 95th percentile for age/sex OR
• 2. BMI ≥ 30 kg/m^2 OR
• 3. BMI ≥ 85th percentile with ≥1 weight‑related comorbidity (e.g., hypertension, dyslipidemia, type 2 diabetes, OSA) AND
• 3. Inadequate response to ≥6‑month regimen of low‑calorie diet, increased physical activity, behavioral modification AND
• 4. If requested agent is Saxenda, ONE of:
• A. Adult: starting therapy OR <16 weeks therapy OR ≥4% weight loss maintained OR
• B. Pediatric (12–17 years): starting therapy OR <20 weeks therapy OR ≥1% BMI reduction maintained
• 5. If requested agent is Wegovy, ONE of:
• A. Starting therapy OR <52 weeks therapy OR (adult) ≥5% weight loss maintained OR (pediatric) ≥5% BMI reduction maintained
• 6. If requested agent is Zepbound, ONE of:
• A. Starting therapy OR <52 weeks therapy OR ≥5% weight loss maintained
• E. Other FDA‑labeled indication for requested agent/route AND
• 2. NOT used in combination with another weight‑loss agent (Contrave, phentermine, Qsymia, Xenical) AND
• 3. BOTH of:
• A. Currently on low‑calorie diet, increased physical activity, behavioral modification regimen AND
• B. Will continue regimen with agent AND
• 4. Age within FDA labeling for indication OR supported use AND
• 5. NOT used with another GLP‑1 receptor agonist (Saxenda, Wegovy, Zepbound, Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza) AND
• 6. No FDA‑labeled contraindications

Reauthorization criteria

• 1. Patient previously approved for therapy with Wegovy, Saxenda, or Zepbound through plan’s PA process AND
• 2. ONE of:
• A. Diagnosis of OSA AND BOTH:
• 1. Requested agent is Zepbound AND
• 2. Clinical benefit (e.g., reduction in AHI or Epworth Sleepiness Scale) demonstrated OR
• B. Diagnosis of NASH or MASH AND ALL of (medical records required):
• 1. Requested agent is Wegovy AND
• 2. Alcohol consumption limits maintained (female <20 g/day OR male <30 g/day)

Approval duration

12 months; Saxenda adults 4 months; Saxenda pediatrics 5 months