Pharmacy Prior Authorization Criteria

Wegovy cardiovascular risk reduction-EHB

For diagnosis of Reduce the risk of major adverse cardiovascular events
Indicated in combination with a reduced calorie diet and increased physical activity to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in adults with established cardiovascular disease and either obesity or overweight.
Limitations of Use: Wegovy contains semaglutide and should not be coadministered with other semaglutide-containing products or with any other GLP-1 receptor agonist. The safety and effectiveness of Wegovy in combination with other products intended for weight loss, including prescription drugs, over-the-counter drugs, and herbal preparations, have not been established. Wegovy has not been studied in patients with a history of pancreatitis.

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Reduce the risk of major adverse cardiovascular events

Treatment is being requested to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke)

AND

AND

Submission of medical records (e.g., chart notes) documenting patient has established cardiovascular disease as evidenced by one of the following:

Prior myocardial infarction (MI)
Prior stroke (i.e., transient ischemic attack, ischemic or hemorrhagic stroke)
Peripheral arterial disease (i.e., intermittent claudication with ankle-brachial index < 0.85, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease)

AND

Submission of medical records (e.g., chart notes) documenting that medication is being used in combination with a program supporting a reduced calorie diet of at least 500 kcal/day and patient can be active for at least 150 minutes per week

AND

Submission of medical records (e.g., chart notes) documenting BMI greater than or equal to 27 kg/m2

AND

Submission of medical records (e.g., chart notes) documenting HbA1c less than 6.5% in the past 12 months

AND

Submission of medical records (e.g., chart notes) documenting patient does not have any of the following:

AND

Submission of medical records (e.g., chart notes) or absence of paid claims confirming medication is not being co-administered with any of the following:

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Reduce the risk of major adverse cardiovascular events

Submission of medical records (e.g., chart notes) documenting that patient demonstrated medication adherence (e.g., 80% adherence to treatment) over prior 6 months

AND

Submission of medical records (e.g., chart notes) documenting that medication is being used in combination with a program supporting a reduced calorie diet of at least 500 kcal/day and patient can be active for at least 150 minutes per week

AND

Paid claims or submission of medical records (e.g., chart notes) documenting patient is receiving a dose of 1.7mg or 2.4mg per week

AND

Submission of medical records (e.g., chart notes) documenting HbA1c less than 6.5% in the past 12 months

AND

Submission of medical records (e.g., chart notes) documenting patient does not have any of the following:

AND

Submission of medical records (e.g., chart notes) or absence of paid claims confirming medication is not being co-administered with any of the following: