Wegovy — Highmark
chronic weight management in adults
Preferred products
- generic liraglutide
Initial criteria
- age ≥ 18 years
- drug used for chronic weight management (ICD-10: E66.0, E66.3)
- prescriber attests baseline height, weight, and BMI
- baseline BMI ≥ 30 kg/m2 OR baseline BMI ≥ 27 kg/m2 with a weight related comorbidity (e.g., hypertension, cardiovascular disease, dyslipidemia, obstructive sleep apnea)
- 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 ≥ 18 years
- drug used for chronic weight management (ICD-10: E66.0, E66.3)
- prescriber attests baseline and current height, weight, and BMI
- baseline BMI ≥ 30 kg/m2 OR baseline BMI ≥ 27 kg/m2 with a weight related comorbidity (e.g., hypertension, cardiovascular disease, dyslipidemia, obstructive sleep apnea)
- 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 ≥ 4% weight loss from baseline AND dose 2.4 mg or 3 mg daily (or titrating)
- for Wegovy: experienced ≥ 5% weight loss from baseline AND dose 1.7 mg or 2.4 mg once weekly (or titrating)
- for Zepbound: experienced ≥ 5% weight loss from baseline AND dose 5 mg–15 mg once weekly (or titrating)
- if brand Saxenda requested: therapeutic failure or intolerance to plan-preferred generic liraglutide
- for maintenance (≥12 months): member has maintained same required weight loss thresholds and continues on appropriate dose as above