Wegovy — Blue Cross Blue Shield of New Mexico

Initial criteria

• The requested quantity (dose) does NOT exceed the program quantity limit OR if it exceeds the limit, one of the following is met:
• If requested agent is Wegovy 0.5 mg or 1 mg and intended use is for maintenance therapy, BOTH: patient unable to use FDA-labeled strength for maintenance AND has had clinical benefit on the lower requested strength from baseline
• Requested agent does NOT have a maximum FDA labeled dose for requested indication AND there is support for therapy with a higher dose
• Requested quantity (dose) does NOT exceed maximum FDA labeled dose AND there is support why requested quantity cannot be achieved with lower quantity of higher strength that meets limit
• Requested quantity (dose) exceeds maximum FDA labeled dose AND there is support for therapy with higher dose for requested indication

Approval duration

12 months (BCBSIL FI & HIM); initial for Wegovy/Zepbound 12 months; Saxenda pediatric 5 months; Saxenda adult 4 months; renewal 12 months