Wegovy — Highmark

Initial criteria

• The prescriber provides documentation that the member continues to use standard of care pharmacologic treatment to manage comorbid diseases (for example, cardiovascular disease, dyslipidemia, diabetes, hypertension).
• The prescriber provides documentation that the member does not have evidence of cirrhosis, hepatic decompensation, or hepatocellular carcinoma (HCC).
• The prescriber provides documentation that the member’s alcohol consumption is ≤ 20 g/day in females or ≤ 30 g/day for males.
• The member will NOT be using the requested medication in combination with any GLP-1 receptor agonist (RA) or GLP-1 RA combination (for example, with insulin, GIP RA).
• The requested dose is 1.7 mg or 2.4 mg once weekly OR the prescriber attests that the member is titrating to a dose of 1.7 mg or 2.4 mg once weekly.

Reauthorization criteria

• The prescriber provides documentation that the member continues to meet initial criteria.

Approval duration

initial: 6 months; reauthorization: 12 months