Wegovy PA Policy 4774-A 08-2022 v2 (2024)

Subject: Wegovy PA Policy 4774-A 08-2022 v2

Policy:

FDA-approved Indications
Wegovy is indicated as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in:
• adults with an initial body mass index (BMI) of:
º 30 kg/m²or greater (obesity), or
º 27 kg/m²or greater (overweight) in the presence of at least
one weight-related comorbid condition (e.g., hypertension,
type 2 diabetes mellitus, or dyslipidemia)
• pediatric patients aged 12 years and older with an initial BMI at the
95^thpercentile or greater standardized for age and sex (obesity)

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

COVERAGE CRITERIA
The requested drug will be covered with prior authorization when the following criteria are met:
• The patient is 18 years of age or older
AND
º The patient has completed at least 3 months of therapy with
the requested drug at a stable maintenance dose
AND
• The patient lost at least 5 percent of baseline body weight
OR the patient has continued to maintain their initial 5
percent weight loss. [Documentation is required for
approval.]
OR
º The requested drug will be used with a reduced calorie diet and
increased physical activity for chronic weight management in
an adult
AND
• The patient has participated in a comprehensive weight
management program that encourages behavioral
modification, reduced calorie diet and increased physical
activity with continuing follow-up for at least 6 months
prior to using drug therapy
AND
• The patient has a body mass index (BMI) greater than
or equal to 30 kilogram per square meter
OR
• The patient has a body mass index (BMI) greater than
or equal to 27 kilogram per square meter AND has at
least one weight related comorbid condition (e.g.,
hypertension, type 2 diabetes mellitus or dyslipidemia)
OR
• The patient is 12 to 17 years of age
AND
º The request is for continuation of therapy for a patient that
has successfully titrated to a stable maintenance dose
AND
• The patient has a reduction from their baseline body
mass index (BMI) OR the patient has continued to
maintain their reduction in BMI from baseline.
[Documentation is required for approval.]
OR
º The requested drug will be used with a reduced calorie diet
and increased physical activity for chronic weight
management
AND
• The patient has participated in a comprehensive weight
management program that encourages behavioral
modification, reduced calorie diet and increased
physical activity with continuing follow-up for at least 6
months prior to using drug therapy
AND
• The patient has an initial body mass index (BMI) in the
95^thpercentile or greater standardized for age and sex
(obesity)

Place of Service:

Outpatient

The above policy is based on the following references:

1. Wegovy [package insert]. Plainsboro, NJ: Novo Nordisk, Inc.; December 2022.
2. Lexicomp Online, AHFS DI (Adult and Pediatric) Online, Hudson, Ohio: UpToDate, Inc.; 2022; Accessed May 25, 2022.
3. Micromedex (electronic version). IBM Watson Health, Greenwood Village, Colorado, USA. Available at: https://www.micromedexsolutions.com/. Accessed May 25, 2022.
4. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. National Heart, Lung, and Blood Institute. NIH Publication No. 12-7486. October 2012. http://www.nhlbi.nih.gov/guidelines/cvd_ped/peds_guidelines_full.pdf. 141-159. Accessed May 17, 2022.
5. Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism, Volume 100, Issue 2, 1 February 2015, Pages 342–362. https://academic.oup.com/jcem/article/100/2/342/2813109. Accessed May 17, 2022.
6. Jensen MD, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. 2013; 129:S102–S138

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

March 15, 2023

Additional Information