Wegovy (semaglutide) — United Healthcare

Initial criteria

• Treatment is being requested to reduce the risk of major adverse cardiovascular events
• age ≥ 45 years
• Submission of medical records documenting ALL of the following: BMI ≥ 27 kg/m2 AND established cardiovascular disease as evidenced by ONE of the following: prior myocardial infarction (MI); prior ischemic or hemorrhagic stroke; symptomatic peripheral arterial disease (PAD) evidenced by ONE of the following: intermittent claudication with ankle-brachial index (ABI) < 0.85 (at rest); peripheral arterial revascularization procedure; amputation due to atherosclerotic disease
• Used in combination with a reduced calorie diet and increased physical activity
• For patients with history of MI: Patient is on therapy from EACH of the following classes unless there is a contraindication or intolerance: cholesterol lowering medication (e.g., statin, PCSK9i); beta blocker (carvedilol, metoprolol, or bisoprolol); ACE-I, ARB or ARNI; antiplatelet (e.g., aspirin, clopidogrel) OR For patients with history of ischemic or hemorrhagic stroke: Patient is on therapy from EACH of the following classes unless there is a contraindication or intolerance: cholesterol lowering medication (e.g., statin, PCSK9); ACE-I, ARB or ARNI; antiplatelet (e.g., aspirin, clopidogrel) OR For patients with history of symptomatic PAD: Patient is on therapy from EACH of the following classes unless there is a contraindication or intolerance: cholesterol lowering medication (e.g., statin, PCSK9); ACE-I, ARB or ARNI; antiplatelet (e.g., aspirin, clopidogrel)
• Patient does not have diagnosis of diabetes or HbA1c > 6.5%
• Patient does not have New York Heart Association class IV heart failure

Reauthorization criteria

• BMI ≥ 27 kg/m2
• Used in combination with a reduced calorie diet and increased physical activity
• Patient does not have diagnosis of diabetes or HbA1c > 6.5%
• Patient does not have New York Heart Association class IV heart failure

Approval duration

12 months