Wegovy — Cigna

Initial criteria

• Patient is ≥ 18 years of age
• Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months
• Patient meets ONE of the following (a or b): a) At baseline, patient had a BMI ≥ 30 kg/m2; OR b) Patient meets BOTH of the following [(1) and (2)]: (1) At baseline, patient had a BMI ≥ 27 kg/m2; AND (2) At baseline, patient had, or currently has, at least ONE of the following weight-related comorbidities: hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, cardiovascular disease, knee osteoarthritis, asthma, chronic obstructive pulmonary disease, metabolic dysfunction-associated steatotic liver disease/non-alcoholic fatty liver disease, polycystic ovarian syndrome, or coronary artery disease
• The medication will be used concomitantly with behavioral modification and a reduced-calorie diet

Reauthorization criteria

• Patient is ≥ 18 years of age
• Patient met baseline BMI ≥ 30 kg/m2 OR both of the following: (1) At baseline BMI ≥ 27 kg/m2; AND (2) baseline or current weight-related comorbidity present
• Patient has lost ≥ 5% of baseline body weight
• The medication will be used concomitantly with behavioral modification and a reduced-calorie diet

Approval duration

initial 7 months, reauth 1 year