Wegovy — Cigna

Initial criteria

• Patient is ≥ 18 years of age
• Patient does not have cirrhosis
• The diagnosis of MASH/NASH is confirmed by ONE of the following: (a) Liver biopsy performed within 3 years preceding Wegovy treatment showing NAFLD activity score ≥ 4 with a score ≥ 1 in steatosis, ballooning, and lobular inflammation; OR (b) Imaging exam performed within 6 months preceding treatment (elastography, computed tomography, or magnetic resonance imaging)
• Prior to treatment, patient has stage F2 or F3 fibrosis (documentation required)
• Prescriber confirms at least ONE metabolic risk factor managed according to standard of care: central obesity, hypertriglyceridemia, reduced HDL cholesterol, hypertension, elevated fasting plasma glucose (diabetes or pre-diabetes)
• Female patient: alcohol consumption < 20 grams/day OR Male patient: alcohol consumption < 30 grams/day
• The medication will be used in combination with appropriate diet and exercise therapy
• The medication is prescribed by or in consultation with an endocrinologist, gastroenterologist, or hepatologist

Reauthorization criteria

• Patient has completed ≥ 1 year of therapy with Wegovy and has not had worsening of fibrosis or MASH/NASH
• Patient has not progressed to stage F4 (cirrhosis)
• Prescriber attests metabolic risk factors are managed according to standard of care
• Female patient: alcohol consumption < 20 grams/day OR Male patient: alcohol consumption < 30 grams/day
• The medication will be used in combination with appropriate diet and exercise therapy
• The medication is prescribed by or in consultation with an endocrinologist, gastroenterologist, or hepatologist

Approval duration

1 year