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Zepbound — Blue Cross Blue Shield of Montana

obstructive sleep apnea (OSA)

Initial criteria

  • Diagnosis of OSA with polysomnography or home sleep apnea test showing apnea-hypopnea index ≥ 15 events/hour (baseline prior to therapy)
  • Requested agent is Zepbound
  • Pretreatment BMI ≥ 30 kg/m^2
  • OR diagnosis of NASH or MASH with stage F1–F3 fibrosis confirmed by FIB-4 score and one of liver biopsy, VCTE, ELF score or MRE
  • Requested agent is Wegovy
  • Patient age ≥ 18 years
  • Pretreatment BMI > 25 kg/m^2 OR > 23 kg/m^2 if of South Asian, Southeast Asian, or East Asian descent
  • Alcohol use < 20 g/day for females OR < 30 g/day for males
  • Patient monitored/treated for comorbidities (cardiovascular disease, diabetes, dyslipidemia, hypertension)
  • No decompensated cirrhosis, moderate/severe hepatic impairment, or other chronic liver disease
  • Prescriber is or has consulted a relevant specialist
  • OR for risk reduction of major adverse cardiovascular events, patient has established atherosclerotic cardiovascular disease (e.g., MI, stroke, PAD)
  • Requested agent is Wegovy
  • Pretreatment BMI ≥ 27 kg/m^2
  • Patient will use optimized pharmacotherapy for established cardiovascular disease with agent
  • OR for weight management, patient new to therapy/new to plan/or repeating course
  • Adult (age ≥ 18 years) with BMI ≥ 30 kg/m^2 OR ≥ 25 kg/m^2 if Asian descent OR ≥ 27 kg/m^2 with ≥ 1 weight-related comorbidity
  • OR pediatric (age 12–17 years) with BMI ≥ 95th percentile OR ≥ 30 kg/m^2 OR ≥ 85th percentile with ≥ 1 weight-related comorbidity
  • Inadequate response to ≥ 6 months of low-calorie diet, physical activity, and behavioral modification
  • If requested agent is Saxenda: starting therapy OR <16 weeks (<20 weeks for pediatric) OR weight/BMI reduction goals met
  • If Wegovy: starting therapy OR <52 weeks OR ≥5% weight reduction from baseline (adults or pediatric BMI reduction ≥5%)
  • If Zepbound: starting therapy OR <52 weeks OR ≥5% weight reduction from baseline
  • Agent will not be used in combination with another weight-loss agent
  • Patient is on and will continue low-calorie diet, physical activity, and behavioral modifications
  • Age within FDA labeling or supported for requested indication
  • Agent will not be used with another GLP-1 receptor agonist
  • No FDA-labeled contraindications

Reauthorization criteria

  • Previously approved for Wegovy, Saxenda, or Zepbound
  • For OSA: requested agent is Zepbound and patient has achieved clinical benefit (e.g., reduction in AHI, decrease in Epworth Sleepiness Scale)
  • For NASH/MASH: requested agent is Wegovy and patient maintains limited alcohol use (<20 g/day female, <30 g/day male)

Approval duration

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