Zepbound — Blue Cross Blue Shield of Kansas

Initial criteria

• Obesity is NOT restricted from coverage under the patient's benefit AND ONE of the following:
• A. Obstructive sleep apnea (OSA) indication: • Patient has had a polysomnography (PSG) or home sleep apnea test AND • Apnea hypopnea index (AHI) ≥ 15 events/hour from baseline prior to pharmacotherapy AND • Requested agent is Zepbound AND • Patient has BMI ≥ 30 kg/m^2
• B. Cardiovascular risk reduction indication (reduce risk of cardiovascular death, non-fatal MI, or non-fatal stroke): • Requested agent is FDA-labeled for the requested indication and route of administration AND • Patient has history of myocardial infarction OR stroke OR peripheral artery disease (intermittent claudication with ankle-brachial index <0.85 at rest, or peripheral arterial revascularization, or amputation due to atherosclerotic disease) AND • BMI ≥ 27 kg/m^2 AND • Patient will use optimized pharmacotherapy for established CVD in combination with requested agent
• C. Weight management indication: • Patient is new to therapy, new to Prime, or attempting a repeat weight loss course AND • ONE of the following: – Adult (age ≥ 18 years) with BMI ≥ 30 kg/m^2 OR BMI ≥ 25 kg/m^2 if South Asian, Southeast Asian, or East Asian OR BMI ≥ 27 kg/m^2 with at least one weight-related comorbidity (hypertension, type 2 diabetes mellitus, obstructive sleep apnea, cardiovascular disease, dyslipidemia) – Pediatric (age 12–17 years) with BMI ≥ 95th percentile for age/sex OR BMI ≥ 30 kg/m^2 OR BMI ≥ 85th percentile for age/sex with at least one comorbidity (hypertension, dyslipidemia, type 2 diabetes, obstructive sleep apnea) • Patient has engaged in a weight loss regimen of low-calorie diet, increased physical activity, and behavioral modifications for ≥ 6 months AND • ONE of the following: – Patient has NOT tried a targeted weight loss agent (e.g., Saxenda, Wegovy, Zepbound) in the past 12 months OR – Patient has tried targeted agent previously and meets conditions for reattempt