Wegovy — Blue Cross Blue Shield of Illinois

Initial criteria

• The patient does NOT have decompensated cirrhosis, moderate to severe hepatic impairment (Child-Pugh Class B or C), or any other liver disease (e.g., Wilson's disease, hepatocellular carcinoma, hepatitis)
• The patient has had clinical benefit with the requested agent
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., hepatologist, gastroenterologist) or has consulted with a specialist in the area of the patient’s diagnosis
• For cardiovascular risk reduction indication, ALL of the following: 1) The requested agent is Wegovy; 2) The patient will use optimized pharmacotherapy for established cardiovascular disease in combination with the requested agent; 3) The patient has had clinical benefit with the requested agent
• For weight management indication, ALL of the following: 1) The patient is continuing a current weight loss course of therapy; 2) If the patient is pediatric (age 12–17 years), BMI ≥ 85th percentile for age and sex; 3) The patient meets ONE of the following:
• If the requested agent is Saxenda, ONE of the following: a) pediatric (age 12–17 years) AND BMI reduction ≥ 1% from baseline; OR b) adult (age ≥ 18 years) AND weight loss ≥ 4% from baseline
• If the requested agent is Wegovy, ONE of the following: a) patient has received < 52 weeks of therapy on maximum tolerated dose; OR b) pediatric (age 12–17 years) AND BMI reduction ≥ 5% from baseline
• If the requested agent is Zepbound, ONE of the following: a) patient has received < 52 weeks of therapy on maximum tolerated dose; OR b) patient has achieved and maintained ≥ 5% weight loss from baseline
• The patient has another FDA labeled indication for the requested agent and route AND has had clinical benefit with the requested agent
• The patient will NOT use the requested agent in combination with another weight-loss agent (e.g., Contrave, phentermine, Qsymia, Xenical)
• The patient is currently on a weight management regimen including a low-calorie diet, increased physical activity, and behavioral modifications, and will continue regimen with the requested agent
• The patient will NOT use the requested agent in combination with another GLP-1 receptor agonist (e.g., Saxenda, Wegovy, Zepbound, Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza)
• The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• Continuation of therapy (renewal) may be approved if patient continues to meet initial criteria and has had clinical benefit with the requested agent

Approval duration

12 months