Wegovy — Highmark
chronic weight management in adolescents or adults who initiated as adolescents
Preferred products
- generic liraglutide
Initial criteria
- age ≥ 12 years
- drug used for chronic weight management (ICD-10: E66.0)
- prescriber attests baseline age, height, weight, and BMI
- for Saxenda: baseline body weight ≥ 60 kg AND baseline BMI ≥ 30 kg/m2 or greater for adults based on Cole Criteria
- for Wegovy: baseline BMI ≥ 95th percentile for age and sex based on CDC Criteria
- member actively participated for ≥ 3 months prior to initiation in lifestyle modification program (reduced calorie diet and increased physical activity)
- use in combination with lifestyle modification program (reduced calorie diet and increased physical activity)
- not used in combination with any GLP-1 RA or GLP-1 RA combinations (e.g., with insulin, GIP RA)
- if brand Saxenda requested: therapeutic failure or intolerance to plan-preferred generic liraglutide
Reauthorization criteria
- age ≥ 12 years
- drug used for chronic weight management (ICD-10: E66.0)
- prescriber attests baseline and current age, height, weight, BMI
- for Saxenda: baseline body weight ≥ 60 kg AND baseline BMI ≥ 30 kg/m2 or greater for adults based on Cole Criteria
- for Wegovy: baseline BMI ≥ 95th percentile for age and sex based on CDC Criteria
- use in combination with a lifestyle modification program that encourages reduced calorie diet and increased physical activity
- not used in combination with any GLP-1 RA or GLP-1 RA combinations (e.g., with insulin, GIP RA)
- for Saxenda: experienced and maintained ≥ 1% BMI reduction from baseline AND dose 2.4 mg or 3 mg daily (or titrating)
- for Wegovy: experienced and maintained ≥ 5% BMI reduction from baseline AND dose 1.7 mg or 2.4 mg once weekly (or titrating)
- if brand Saxenda requested: therapeutic failure or intolerance to plan-preferred generic liraglutide