Wegovy — Blue Cross Blue Shield of Montana

Initial criteria

• The patient does NOT have decompensated cirrhosis, moderate to severe hepatic impairment (Child-Pugh Class B or C), or 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 or has consulted a specialist relevant to the patient’s diagnosis (e.g., hepatologist, gastroenterologist)
• For cardiovascular indication: The requested agent is Wegovy AND the patient will use optimized pharmacotherapy for cardiovascular disease AND patient has had clinical benefit with Wegovy
• For weight management indication: The patient is overweight or obese and is continuing a current weight loss therapy AND
• If pediatric (age 12–17 years), BMI ≥ 85th percentile for age and sex
• For Saxenda: pediatric patients have achieved and maintained ≥1% reduction in BMI from baseline OR adults have achieved and maintained ≥4% weight loss from baseline
• For Wegovy: patient has received <52 weeks of therapy at max-tolerated dose OR pediatric patients have achieved and maintained ≥5% BMI reduction from baseline
• For Zepbound: patient has received <52 weeks of therapy at max-tolerated dose OR has achieved and maintained ≥5% weight loss from baseline
• 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 and will continue a weight management regimen including low-calorie diet, increased physical activity, and behavioral modifications
• 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

• Patient continues to have clinical benefit and meets weight or BMI reduction thresholds as defined for requested agent
• Patient remains adherent to low-calorie diet, physical activity, and behavioral modifications regimen
• No new contraindications developed since previous approval

Approval duration

12 months