Wegovy — Blue Cross Blue Shield of New Mexico

Initial criteria

• ONE of the following:
• A. The patient has a diagnosis of obstructive sleep apnea (OSA) [medical records required] AND ALL of the following:
• 1. The patient has had a polysomnography (PSG) or home sleep apnea test AND
• 2. Apnea hypopnea index (AHI) ≥ 15 events/hour from baseline AND
• 3. Requested agent is Zepbound AND
• 4. Pretreatment BMI ≥ 30 kg/m²
• OR
• B. The patient has a diagnosis of noncirrhotic NASH or MASH [medical records required] AND ALL of the following:
• 1. Stage F1, F2, or F3 fibrosis confirmed by BOTH of the following before therapy:
• A. FIB-4 score consistent with stage F1–F3 adjusted for age AND
• B. ONE of: liver biopsy, vibration-controlled transient elastography (VCTE), enhanced liver fibrosis (ELF) score, or magnetic resonance elastography (MRE) AND
• 2. Requested agent is Wegovy AND
• 3. Patient age ≥ 18 years AND
• 4. ONE of the following BMI criteria:
• A. Pretreatment BMI > 25 kg/m² OR
• B. Pretreatment BMI > 23 kg/m² if South Asian, Southeast Asian, or East Asian descent AND
• 5. ONE of the following alcohol criteria:
• A. If female: alcohol consumption < 20 grams/day OR
• B. If male: alcohol consumption < 30 grams/day AND
• 6. Patient is being monitored/treated for comorbid conditions (e.g., cardiovascular disease, diabetes, dyslipidemia, hypertension) AND
• 7. Patient does NOT have any of: decompensated cirrhosis, moderate–severe hepatic impairment (Child-Pugh B or C), or other liver disease (e.g., Wilson’s disease, hepatocellular carcinoma, hepatitis) AND
• 8. Prescriber is a specialist (e.g., hepatologist, gastroenterologist) or has consulted one
• OR
• C. To reduce the risk of major adverse cardiovascular events in adults with established cardiovascular disease and either obesity or overweight AND ALL of the following:
• 1. Requested agent is Wegovy AND
• 2. Patient history includes ONE of: myocardial infarction, stroke, or peripheral artery disease as defined (intermittent claudication with ABI < 0.85, peripheral revascularization, or amputation due to atherosclerotic disease) AND
• 3. Pretreatment BMI ≥ 27 kg/m² AND
• 4. Patient will use optimized pharmacotherapy for established cardiovascular disease in combination with requested agent
• OR
• D. For weight management in overweight or obese patients, ALL of the following:
• 1. Patient is new to therapy, new to Prime, or attempting repeat course of therapy AND
• 2. ONE of the following:
• A. Adult (age ≥ 18 years) with ONE of:
• 1. Pretreatment BMI ≥ 30 kg/m² OR
• 2. Pretreatment BMI ≥ 25 kg/m² if of South/Southeast/East Asian descent OR
• 3. Pretreatment BMI ≥ 27 kg/m² with ≥1 weight-related comorbidity (hypertension, type 2 diabetes, OSA, cardiovascular disease, dyslipidemia)
• OR
• B. Pediatric (age 12–17 years) with ONE of:
• 1. Pretreatment BMI ≥ 95th percentile for age/sex OR
• 2. Pretreatment BMI ≥ 30 kg/m² OR
• 3. Pretreatment BMI ≥ 85th percentile with ≥1 weight-related comorbidity (hypertension, dyslipidemia, type 2 diabetes, OSA) AND
• 3. Inadequate response to ≥6 months of reduced-calorie diet, physical activity, and behavioral modification AND
• 4. If requested agent is Saxenda, ONE of:
• A. Adult (≥18 years) AND ONE of: starting therapy, <16 weeks of prior therapy, or ≥4% weight loss from baseline OR
• B. Pediatric (12–17 years) AND ONE of: starting therapy, <20 weeks prior therapy, or ≥1% BMI reduction from baseline AND
• 5. If requested agent is Wegovy, ONE of:
• A. Starting therapy OR
• B. <52 weeks prior therapy OR
• C. Adult (≥18 years) with ≥5% weight loss from baseline OR
• D. Pediatric (12–17 years) with ≥5% BMI reduction from baseline AND
• 6. If requested agent is Zepbound, ONE of:
• A. Starting therapy OR
• B. <52 weeks prior therapy OR
• C. ≥5% weight loss from baseline AND
• E. The patient has another FDA-labeled indication for the requested agent and route of administration AND
• 2. Requested agent not used in combination with another weight-loss drug (e.g., Contrave, phentermine, Qsymia, Xenical) AND
• 3. BOTH of the following:
• A. Patient currently on a reduced-calorie diet, increased physical activity, and behavioral modifications AND
• B. Will continue regimen in combination with requested agent AND
• 4. If indicated, patient age is within FDA labeling for requested use or supported for off-label age use AND
• 5. Requested agent not used concurrently with another GLP-1 receptor agonist (e.g., Saxenda, Wegovy, Zepbound, Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza) AND
• 6. No FDA-labeled contraindications to requested agent

Reauthorization criteria

• 1. Patient previously approved for therapy with Wegovy, Saxenda, or Zepbound through plan’s PA process AND
• 2. ONE of the following:
• A. Diagnosis of obstructive sleep apnea (OSA) AND BOTH:
• 1. Requested agent is Zepbound AND
• 2. Clinical benefit shown (e.g., reduction in AHI, decreased Epworth Sleepiness Scale) OR
• B. Diagnosis of noncirrhotic NASH or MASH [medical records required] AND ALL of the following:
• 1. Requested agent is Wegovy AND
• 2. ONE of the following alcohol consumption criteria:
• A. If female: <20 grams/day OR
• B. If male: <30 grams/day

Approval duration

12 months (Wegovy, Zepbound); 4 months (Saxenda adults); 5 months (Saxenda pediatrics)