Skip to content
The Policy VaultThe Policy Vault

Zepbound — Blue Cross Blue Shield of Texas

reduction of risk of major adverse cardiovascular events in adults with established cardiovascular disease and either obesity or overweight

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