Zepbound — Blue Cross Blue Shield of Kansas

Reauthorization criteria

• Patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
• For Qsymia, ONE of the following: - For a pediatric patient (age 12–17 years): achieved and maintained ≥5% reduction of baseline BMI (prior to initiation of the requested agent) OR - BOTH of the following: - ONE of the following: - For a pediatric patient: achieved and maintained <5% reduction of baseline BMI (prior to initiation of the requested agent) OR - For an adult: achieved and maintained <5% weight loss from baseline (prior to initiation of requested agent) AND - BOTH: - Dose is being titrated upward AND - Patient has received <12 weeks of therapy on the highest strength (15 mg/92 mg)
• For Xenical (or Orlistat), ONE of the following: - Patient age 12–16 years AND achieved and maintained >4% weight loss from baseline (prior to initiation of requested agent) OR - Patient age ≥17 years AND achieved and maintained ≥5% weight loss from baseline (prior to initiation of requested agent)
• If not otherwise specified, patient has achieved and maintained ≥5% weight loss from baseline (prior to initiation of requested agent)
• If pediatric, current BMI >85th percentile for age and gender
• Patient is currently on and will continue a low-calorie diet, increased physical activity, and behavioral modifications
• Requested agent will NOT be used in combination with another weight-loss agent (e.g., Contrave, phentermine, Qsymia, Xenical, Saxenda, Wegovy, Zepbound)
• Patient does NOT have any FDA-labeled contraindications to the requested agent

Approval duration

Qsymia ≥5% weight loss: 12 months; Qsymia <5% weight loss: 3 months; all other agents: 12 months