Wegovy — Cigna

Initial criteria

• Patient has had ONE of the following imaging exams performed within the 6 months preceding treatment [documentation required]: elastography OR computed tomography OR magnetic resonance imaging
• Patient meets ONE of the following prior to treatment [documentation required]: stage F2 fibrosis OR stage F3 fibrosis
• According to the prescriber, patient has ONE or more metabolic risk factors managed according to standard of care: central obesity OR hypertriglyceridemia OR reduced high-density lipoprotein cholesterol OR hypertension OR elevated fasting plasma glucose indicative of diabetes or pre-diabetes
• According to the prescriber, patient meets ONE of the following: Female patient: alcohol consumption < 20 grams/day OR Male patient: alcohol consumption < 30 grams/day
• Medication will be used in combination with appropriate diet and exercise therapy
• 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)
• According to the prescriber, metabolic risk factors are managed according to standard of care
• According to the prescriber, patient meets ONE of the following: Female patient: alcohol consumption < 20 grams/day OR Male patient: alcohol consumption < 30 grams/day
• Medication will be used in combination with appropriate diet and exercise therapy
• Medication is prescribed by or in consultation with an endocrinologist, gastroenterologist, or hepatologist

Approval duration

1 year