Wegovy — Highmark
major adverse cardiovascular events risk reduction
Preferred products
- Ozempic
- Praluent
- Repatha
Initial criteria
- age ≥ 18 years
- drug is used for major adverse cardiovascular event risk reduction
- member has diagnosis of myocardial infarction (ICD-10: I21), stroke (ICD-10: I63), or peripheral arterial disease (ICD-10: I73.9) with evidence (ABI <0.85, revascularization, or amputation due to atherosclerotic disease)
- baseline BMI ≥ 27 kg/m2
- member will use Wegovy as adjunct to maximally-tolerated statin therapy and ezetimibe, OR member is statin intolerant and has experienced failure/intolerance to ezetimibe
- member will use or has failed/intolerance/contraindication to a PCSK9 inhibitor (e.g., Praluent, Repatha)
- member maintained healthy dietary changes and increased physical activity ≥6 months prior and will continue both during therapy
- if member has type 2 diabetes (ICD-10: E11.9), must have experienced failure to a preferred GLP-1 RA approved for diabetes and cardiovascular risk reduction (e.g., Ozempic)
- member not using Wegovy with any GLP-1 RA or GLP-1 RA combination products
Reauthorization criteria
- ≥7 months of previous therapy
- age ≥ 18 years
- drug is used for major adverse cardiovascular event risk reduction
- member continues to have diagnosis of myocardial infarction (ICD-10: I21), stroke (ICD-10: I63), or peripheral arterial disease (ICD-10: I73.9) with supporting documentation
- baseline BMI ≥ 27 kg/m2
- member continues adjunct use with maximally tolerated statin and ezetimibe OR is statin intolerant with failure/intolerance to ezetimibe
- member continues adjunct use with or has failed/intolerance/contraindication to a PCSK9 inhibitor (e.g., Praluent, Repatha)