Wegovy — Blue Cross Blue Shield of Texas

Initial criteria

• The patient does NOT have decompensated cirrhosis, moderate to severe hepatic impairment (Child-Pugh Class B or C), or other liver disease
• The prescriber is a specialist in, or has consulted with a specialist in, the area of the patient's diagnosis (e.g., hepatologist, gastroenterologist)
• For cardiovascular risk reduction: requested agent is Wegovy AND the patient uses optimized pharmacotherapy for established cardiovascular disease AND the patient has had clinical benefit with the requested agent
• For weight management: patient continues a current weight loss course of therapy AND follows a regimen of low-calorie diet, increased physical activity, and behavioral modifications AND will continue that regimen
• If patient is pediatric (age 12–17 years), BMI ≥ 85th percentile for age and sex
• For Saxenda: pediatric patients (age 12–17) achieved ≥1% BMI reduction from baseline OR adults (age ≥18) achieved ≥4% weight loss from baseline
• For Wegovy: patient received <52 weeks of therapy on maximum-tolerated dose OR pediatric patient achieved ≥5% BMI reduction from baseline
• For Zepbound: patient received <52 weeks therapy on maximum-tolerated dose OR achieved ≥5% weight loss from baseline
• The patient has had clinical benefit with the requested agent
• The patient will NOT be using the requested agent in combination with another weight-loss agent (e.g., Contrave, phentermine, Qsymia, Xenical)
• The patient will NOT be using 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 has had clinical benefit with the requested agent
• The patient continues participation in a low-calorie diet, increased physical activity, and behavioral modification program
• Weight/BMI reduction thresholds continue to be met per agent-specific criteria

Approval duration

initial 4–5 months (Saxenda) or 12 months (Wegovy, Zepbound); renewal 12 months