Wegovy — Blue Cross Blue Shield of Oklahoma

Initial criteria

• 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)
• Patient has had clinical benefit with the requested agent
• Prescriber is a specialist in or has consulted with a specialist in the patient’s diagnosis (e.g., hepatologist, gastroenterologist)
• Requested agent is Wegovy when used to reduce risk of major adverse cardiovascular events and patient will use optimized pharmacotherapy for established cardiovascular disease in combination with the requested agent
• For weight management use: patient is overweight or obese and continuing a current weight loss course of therapy
• If pediatric (age 12–17 years): current BMI ≥85th percentile for age and sex
• For Saxenda: (a) if pediatric 12–17 years, achieved and maintained reduction in BMI ≥1% from baseline; OR (b) if age ≥18 years, achieved and maintained weight loss ≥4% from baseline
• For Wegovy: (a) received less than 52 weeks of therapy on the maximum‑tolerated dose; OR (b) if pediatric 12‑17 years, achieved and maintained reduction in BMI ≥5% from baseline
• For Zepbound: (a) received less than 52 weeks of therapy on maximum‑tolerated dose; OR (b) achieved and maintained weight loss ≥5% from baseline prior to initiation
• Patient will NOT use the requested agent in combination with another weight loss agent (e.g., Contrave, phentermine, Qsymia, Xenical)
• Patient is currently on and will continue a weight management regimen of low‑calorie diet, increased physical activity, and behavioral modifications in combination with the requested agent
• Patient will NOT use the requested agent with another GLP‑1 receptor agonist (e.g., Saxenda, Wegovy, Zepbound, Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza)
• Patient does NOT have any FDA‑labeled contraindications to the requested agent

Reauthorization criteria

• Patient has achieved and maintained required weight loss or BMI reduction thresholds as applicable for the requested agent
• Patient has demonstrated clinical benefit with the requested agent
• Continuation of weight management regimen is documented
• Patient does NOT have new contraindications or disqualifying conditions

Approval duration

initial: Wegovy/Zepbound 12 months; Saxenda pediatric 5 months, adult 4 months; renewal 12 months