Wegovy — Blue Cross Blue Shield of New Mexico

Initial criteria

• The patient does NOT have ANY of the following: decompensated cirrhosis, moderate to severe hepatic impairment (Child-Pugh Class B or C), or any 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 the area of the patient’s diagnosis (e.g., hepatologist, gastroenterologist) OR has consulted with such a specialist
• For cardiovascular risk reduction: The requested agent is Wegovy AND the patient will use optimized pharmacotherapy for established cardiovascular disease in combination with the requested agent AND the patient has had clinical benefit with the requested agent
• For weight management: The patient is overweight or obese and ALL of the following: continuing a current weight loss course of therapy; if pediatric (age 12–17 years) BMI ≥ 85th percentile for age and sex; and meets ONE of the following depending on the agent:
• If Saxenda: (1) Pediatric (age 12–17 years) AND reduction in BMI ≥ 1% from baseline OR (2) Adult (age ≥ 18 years) AND weight loss ≥ 4% from baseline
• If Wegovy: (1) Received < 52 weeks of therapy at max-tolerated dose OR (2) Pediatric (age 12–17 years) AND BMI reduction ≥ 5% from baseline
• If Zepbound: (1) Received < 52 weeks of therapy at max-tolerated dose OR (2) Weight loss ≥ 5% from baseline
• The patient has another FDA labeled indication for the requested agent and route of administration AND has had clinical benefit with the requested agent
• The patient will NOT use the agent in combination with another weight loss agent (e.g., Contrave, phentermine, Qsymia, Xenical)
• The patient is and will continue on a weight management regimen of 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

• The patient continues to meet initial criteria
• The patient has had clinical benefit with the requested agent

Approval duration

12 months