Wegovy — Cigna

Initial criteria

• Patient age ≥ 12 years and < 18 years
• Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months
• At baseline, patient had a BMI ≥ 95th percentile for age and sex
• The medication will be used concomitantly with behavioral modification and a reduced-calorie diet

Reauthorization criteria

• Patient age ≥ 12 years and < 18 years
• At baseline, patient had a BMI ≥ 95th percentile for age and sex
• Patient has had a reduction in BMI of ≥ 1% from baseline
• The medication will be used concomitantly with behavioral modification and a reduced-calorie diet

Approval duration

initial 7 months, reauth 1 year