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Zepbound — Blue Cross Blue Shield of Texas

weight management

Initial criteria

  • Diagnosis of ONE of the following:
  • A. Obstructive sleep apnea (OSA) AND ALL of the following: polysomnography (PSG) or home sleep apnea test performed; AHI ≥ 15 events/hour prior to pharmacotherapy; requested agent is Zepbound; pretreatment BMI ≥ 30 kg/m^2
  • B. Noncirrhotic NASH or MASH AND ALL of the following: stage F1–F3 fibrosis confirmed by BOTH FIB-4 score adjusted for age and either liver biopsy, VCTE, ELF, or MRE; requested agent is Wegovy; age ≥ 18 years; pretreatment BMI > 25 kg/m^2 (or > 23 kg/m^2 if South Asian, Southeast Asian, or East Asian descent); alcohol consumption below sex-specific limits (female < 20 g/day, male < 30 g/day); monitored/treated for comorbidities; no decompensated cirrhosis, moderate/severe hepatic impairment, or other liver disease; prescriber or consult is hepatologist/gastroenterologist
  • C. To reduce risk of major adverse cardiovascular events (CVD death, nonfatal MI, nonfatal stroke) in adults with established CVD AND ALL of the following: requested agent is Wegovy; history of myocardial infarction, stroke, or peripheral artery disease; pretreatment BMI ≥ 27 kg/m^2; optimized pharmacotherapy for established CVD in combination
  • D. Overweight or obese patients using the agent for weight management AND ALL of the following:
  •  1. Patient is new to therapy, new to plan, or repeating weight loss course
  •  2. ONE of the following:
  •   a. Adult (age ≥ 18 years) with EITHER: pretreatment BMI ≥ 30 kg/m^2, OR BMI ≥ 25 kg/m^2 if South/Southeast/East Asian descent, OR BMI ≥ 27 kg/m^2 with at least one comorbidity (hypertension, type 2 diabetes, OSA, CVD, dyslipidemia)
  •   b. Pediatric (age 12–17 years) with EITHER: BMI ≥ 95th percentile for age/sex, OR BMI ≥ 30 kg/m^2, OR BMI ≥ 85th percentile for age/sex plus ≥ 1 comorbidity (hypertension, dyslipidemia, type 2 diabetes, OSA)
  •  3. Inadequate response to at least 6 months of supervised low-calorie diet, physical activity, and behavioral modification
  •  4. Agent-specific additional requirements:
  •   • Saxenda: Adult—starting therapy OR currently treated <4 months OR ≥4% weight loss from baseline; Pediatric—starting therapy OR <5 months therapy OR ≥1% BMI reduction
  •   • Wegovy: Starting therapy OR currently treated <1 year OR Adult—≥5% weight loss maintained OR Pediatric—≥5% BMI reduction maintained
  •   • Zepbound: Starting therapy OR currently treated <1 year OR ≥5% weight loss maintained
  •  5. OR patient has another FDA-labeled indication for requested agent and route
  • Additional general requirements (apply to all indications):
  • • Agent not used with another weight-loss product (Contrave, phentermine, Qsymia, Xenical)
  • • Patient is and will remain on a comprehensive regimen with low-calorie diet, exercise, and behavior modification
  • • Patient age within FDA labeling or appropriate clinical support
  • • Requested agent not used with another GLP-1 receptor agonist
  • • No FDA-labeled contraindications to requested agent

Reauthorization criteria

  • 1. Patient previously approved for therapy with Wegovy, Saxenda, or Zepbound through prior authorization process
  • 2. ONE of the following:
  •  A. OSA: requested agent is Zepbound; patient shows clinical benefit (e.g., reduced AHI, decreased Epworth Sleepiness Scale)
  •  B. NASH or MASH: requested agent is Wegovy; Alcohol consumption within sex-specific limits (female <20 g/day, male <30 g/day)
  •  C. Continuation for other approved indications as applicable (criteria not shown but imply prior benefit continuation)

Approval duration

Saxenda (adult) 4 months; Saxenda (pediatric) 5 months; Wegovy 12 months; Zepbound 12 months