Zepbound — Blue Cross Blue Shield of Oklahoma

Initial criteria

• Diagnosis of OSA with polysomnography or home sleep apnea test AND apnea hypopnea index (AHI) ≥ 15 events/hour prior to initiation AND requested agent is Zepbound AND pretreatment BMI ≥ 30 kg/m^2
• OR diagnosis of noncirrhotic NASH or MASH with stage F1–F3 fibrosis documented by BOTH FIB-4 score and confirmation via biopsy or equivalent test (VCTE, ELF, or MRE) AND requested agent is Wegovy AND age ≥ 18 years AND pretreatment BMI > 25 kg/m^2 or > 23 kg/m^2 if South/Southeast/East Asian AND alcohol consumption < 20 g/day (female) or < 30 g/day (male) AND patient monitored/treated for comorbid conditions AND no decompensated cirrhosis, no moderate–severe hepatic impairment, no other liver disease AND prescriber is or has consulted a specialist
• OR use to reduce risk of major adverse cardiovascular events in adults with established cardiovascular disease (CAD, ACS, MI, angina, revascularization, stroke, TIA, PAD, aortic aneurysm) AND requested agent is Wegovy AND history of MI or stroke or PAD (ABI < 0.85, procedure, or amputation) AND pretreatment BMI ≥ 27 kg/m^2 AND use in combination with optimized pharmacotherapy for cardiovascular disease
• OR use for weight management in overweight or obese patient meeting ALL: new to therapy/new to plan/repeat weight loss attempt AND either (adult ≥ 18 years with BMI ≥ 30, or BMI ≥ 25 if of South/Southeast/East Asian descent, or BMI ≥ 27 with comorbidity) OR (pediatric 12–17 years with BMI ≥ 95th percentile, or BMI ≥ 30, or BMI ≥ 85th percentile with comorbidity) AND inadequate response to ≥ 6 months of low-calorie diet, physical activity, and behavioral modification AND (if Saxenda: age ≥ 18 and starting therapy or < 16 weeks therapy or ≥ 4% weight loss, or pediatric 12–17 and starting therapy or < 20 weeks therapy or ≥ 1% BMI reduction) AND (if Wegovy: starting or < 52 weeks therapy or ≥ 5% weight loss (adult) or ≥ 5% BMI reduction (pediatric)) AND (if Zepbound: starting or < 52 weeks therapy or ≥ 5% weight loss) AND patient will not use in combination with another weight loss drug or GLP‑1 agonist AND patient currently and will continue to follow low-calorie diet, physical activity, behavioral program AND patient age within FDA labeling or supported AND no FDA labeled contraindications

Reauthorization criteria

• Previously approved for therapy with Wegovy, Saxenda, or Zepbound through plan’s prior authorization process AND ONE of the following applies:
• — For OSA: diagnosis of obstructive sleep apnea AND requested agent is Zepbound AND documented clinical benefit (e.g., reduction in AHI or Epworth Sleepiness Scale)
• — For NASH/MASH: diagnosis confirmed AND requested agent is Wegovy AND alcohol consumption < 20 g/day (female) or < 30 g/day (male)

Approval duration

Wegovy and Zepbound: 12 months; Saxenda adults: 4 months; Saxenda pediatric: 5 months