Wegovy (semaglutide) injection — CareFirst (Caremark)

Initial criteria

• The requested drug will be used with a reduced-calorie diet AND increased physical activity to reduce excess body weight or maintain weight reduction long term
• The patient has participated in a comprehensive weight management program that encourages behavioral modification, reduced-calorie diet, AND increased physical activity with continuing follow-up for at least 6 months prior to using drug therapy
• If the patient is age ≥ 18 years, then the patient meets ONE of the following:
• – Baseline body mass index (BMI) ≥ 30 kg/m2; OR
• – Baseline BMI ≥ 27 kg/m2 AND at least ONE weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia)
• If the patient is age 12–17 years, then baseline BMI is in the 95th percentile or greater standardized for age and sex (obesity)

Reauthorization criteria

• Requested drug will be used with a reduced-calorie diet AND increased physical activity
• If the patient is age ≥ 18 years, all of the following are met:
• – The patient has completed at least 3 months of therapy with the requested drug at a stable maintenance dose
• – The patient has lost at least 5% of baseline body weight OR has continued to maintain at least 5% weight loss
• If the patient is age 12–17 years, all of the following are met:
• – The patient has successfully titrated to a stable maintenance dose
• – The patient has had a reduction from baseline BMI OR has continued to maintain their initial BMI reduction

Approval duration

Initial: 7 months; Continuation: 12 months