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Wegovy — Highmark

chronic weight management

Preferred products

  • generic liraglutide

Initial criteria

  • Saxenda: 0 to < 4 months of previous therapy; Wegovy: 0 to < 6 months; Zepbound: 0 to < 7 months
  • age ≥ 18 years
  • using drug for chronic weight management (ICD-10: E66.0, E66.3)
  • prescriber attests baseline height, weight, BMI
  • baseline BMI ≥ 30 kg/m2 OR baseline BMI ≥ 27 kg/m2 with a weight related comorbidity (for example hypertension, cardiovascular disease, dyslipidemia, obstructive sleep apnea)
  • actively participated ≥ 3 months prior in a lifestyle modification program that encourages reduced calorie diet and increased physical activity AND will use therapy in combination with the program
  • will not be using in combination with GLP-1 RA or GLP-1 RA combinations (for example, with insulin, GIP RA)
  • If brand Saxenda requested: therapeutic failure or intolerance to plan-preferred generic liraglutide

Reauthorization criteria

  • Continuation: Saxenda 4–<12 months; Wegovy 6–<12 months; Zepbound 7–<12 months OR Maintenance: ≥12 months
  • age ≥ 18 years
  • using drug for chronic weight management (ICD-10: E66.0, E66.3)
  • prescriber attests baseline and current height, weight, BMI
  • baseline BMI ≥ 30 kg/m2 OR baseline BMI ≥ 27 kg/m2 with a weight related comorbidity (for example hypertension, cardiovascular disease, dyslipidemia, obstructive sleep apnea)
  • using product in combination with a lifestyle modification program that encourages reduced calorie diet and increased physical activity
  • will not use in combination with GLP-1 RA or GLP-1 RA combinations
  • If Saxenda (liraglutide): experienced ≥ 4% weight loss from baseline (continuation) OR maintained ≥ 4% weight loss from baseline (maintenance) AND dose 2.4 mg or 3 mg daily or titrating to that dose
  • If Wegovy: experienced ≥ 5% weight loss from baseline (continuation) OR maintained ≥ 5% weight loss from baseline (maintenance) AND dose 1.7 mg or 2.4 mg weekly or titrating to that dose
  • If Zepbound: experienced ≥ 5% weight loss from baseline (continuation) OR maintained ≥ 5% weight loss from baseline (maintenance) AND dose 5, 7.5, 10, 12.5, or 15 mg once weekly or titrating to 5 mg weekly
  • If brand Saxenda requested: therapeutic failure or intolerance to plan-preferred generic liraglutide