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The Policy VaultThe Policy Vault

Saxenda — Blue Cross Blue Shield of Kansas

weight management

Initial criteria

  • The patient has tried a targeted weight loss agent for a previous course of therapy in the past 12 months AND
  • The prescriber anticipates success with repeating therapy with any targeted weight loss agent AND
  • If the requested agent is Saxenda, then ONE of the following:
  • A. The patient is an adult (age ≥ 18 years) AND ONE of: starting therapy OR currently treated and has received <16 weeks (4 months) of therapy OR has achieved and maintained weight loss ≥4% from baseline
  • B. The patient is pediatric (age 12–17 years) AND ONE of: starting therapy OR currently treated and has received <20 weeks (5 months) of therapy OR has achieved and maintained reduction in BMI ≥1% from baseline AND
  • If the requested agent is Wegovy, then ONE of the following: starting therapy OR currently treated and has received <52 weeks (1 year) of therapy OR adult (age ≥18 years) and has achieved and maintained weight loss ≥5% from baseline OR pediatric (age 12–17 years) and has achieved and maintained reduction in BMI ≥5% from baseline AND
  • If the requested agent is Zepbound, then ONE of the following: starting therapy OR currently treated and has received <52 weeks (1 year) of therapy OR has achieved and maintained weight loss ≥5% from baseline OR has another FDA-labeled indication for the requested agent and route AND
  • The patient will NOT be using the requested agent in combination with another weight loss agent (e.g., Contrave, phentermine, Qsymia, Xenical) for the requested indication AND
  • BOTH of the following: currently on a weight loss regimen (low-calorie diet, increased physical activity, behavioral modifications) AND will continue regimen with requested agent AND
  • If the patient has an FDA labeled indication, then ONE of: patient’s age is within FDA labeling for the requested indication OR support exists for use in patient’s age AND
  • The patient will NOT use requested agent in combination with another GLP-1 receptor agonist (e.g., Saxenda, Wegovy, Zepbound, Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza) AND
  • The patient does NOT have any FDA-labeled contraindications to the requested agent

Reauthorization criteria

  • Obesity is not restricted from coverage under patient’s benefit AND previously approved through plan’s Prior Authorization AND ONE of the following:
  • A. Diagnosis of obstructive sleep apnea (OSA) AND requested agent is Zepbound AND patient has had clinical benefit (e.g., reduction in AHI, decrease in Epworth Sleepiness Scale) OR
  • B. Requested use is to reduce risk of major adverse cardiovascular events in adults with established cardiovascular disease and obesity/overweight AND ALL of: requested agent is FDA labeled for the indication and route, patient uses optimized pharmacotherapy for established CVD in combination, and patient has had clinical benefit OR
  • C. Patient is overweight or obese and using requested agent for weight management AND ALL of: continuing current weight loss therapy AND if pediatric (age 12–17 years) BMI ≥85th percentile for age and sex AND meets ONE of:
  • A. Saxenda: pediatric achieved and maintained BMI reduction ≥1% from baseline OR adult achieved and maintained weight loss ≥4% from baseline OR
  • B. Wegovy: received <52 weeks of therapy on maximum tolerated dose OR pediatric achieved and maintained BMI reduction ≥5% from baseline OR
  • C. Zepbound: received <52 weeks of therapy on maximum tolerated dose OR achieved and maintained weight loss ≥5% from baseline OR
  • D. Patient has another FDA labeled indication for the requested agent and route AND has had clinical benefit AND
  • Patient will NOT use requested agent with another weight loss agent (e.g., Contrave, phentermine, Qsymia, Xenical) AND BOTH of the following: patient is on and will continue weight loss regimen (low-calorie diet, physical activity, behavior modification) AND will NOT use with another GLP-1 receptor agonist AND patient has no FDA-labeled contraindications

Approval duration

Saxenda: adults 4 months; pediatric 5 months; Wegovy/Zepbound: 12 months; reauth 12 months