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Wegovy (semaglutide) injection — CareFirst (Caremark)

Risk reduction of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in adults with established cardiovascular disease and either obesity or overweight

Initial criteria

  • The requested drug will be used with a reduced-calorie diet AND increased physical activity
  • The patient has established cardiovascular disease with a history of ONE of the following: previous myocardial infarction, previous stroke, symptomatic peripheral arterial disease (as evidenced by intermittent claudication with ankle-brachial index (ABI) < 0.85 (at rest), peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease), or prior history of revascularization (coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or angioplasty)
  • The patient has baseline BMI ≥ 27 kg/m2
  • The patient does NOT have type 2 diabetes
  • The patient is currently receiving guideline-directed management and therapy (GDMT) for cardiovascular disease (e.g., lipid-lowering agent, antiplatelet, beta-blocker, renin-angiotensin inhibitor, etc.) OR has a clinical reason not to be treated with GDMT

Reauthorization criteria

  • The requested drug is being used with a reduced-calorie diet AND increased physical activity
  • The patient continues to have established cardiovascular disease with a history of ONE of the following: previous myocardial infarction, previous stroke, symptomatic peripheral arterial disease, or prior history of revascularization
  • The patient is being treated with a maintenance dosage of the requested drug

Approval duration

Initial: 7 months; Continuation: 12 months