CRITERIA FOR APPROVAL

1

Will the requested drug be used with a reduced-calorie diet AND increased physical activity to reduce excess body weight or maintain weight reduction long term?
[If Yes, then go to 2. If No, then go to 31.]

Yes

No

2

Is the patient 18 years of age or older?
[If Yes, then go to 3. If No, then go to 22.]

Yes

No

3

Has the patient completed at least 3 months of therapy with the requested drug at a stable maintenance dose? [If the patient is transitioning from another drug therapy for weight loss, please answer no and proceed.]
[If Yes, then go to 4. If No, then go to 12.]

Yes

No

4

Did the patient have a baseline body mass index (BMI) of less than 27 kg/m2 at the start of drug therapy for weight loss? [If the patient is transitioning from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy when answering this question.]
[If Yes, then no further questions. If No, then go to 5.]

Yes

No

5

Did the patient have a baseline body mass index (BMI) of 27 kg/m2 to less than 30kg/m2 at the start of drug therapy for weight loss? [If the patient transitioned from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy when answering this question.] ACTION REQUIRED: If yes, then prescriber MUST submit chart notes that show the patient's baseline BMI. (ACTION REQUIRED: Submit supporting documentation.)
[If Yes, then go to 6. If No, then go to 7.]

Yes

No

6

Did the patient have at least ONE of the following weight-related comorbid conditions at the start of drug therapy for weight loss: hypertension, dyslipidemia, type 2 diabetes mellitus, obstructive sleep apnea, cardiovascular disease, metabolic dysfunction-associated steatohepatitis (MASH), metabolic dysfunction-associated steatotic liver disease (MASLD), prediabetes, chronic kidney disease stage 2 or higher, osteoarthritis of the knee and/or hip? [If the patient is transitioning from another drug therapy for weight loss, please consider their weight-related comorbid condition(s) at the start of any drug therapy when answering this question.] ACTION REQUIRED: If yes, then prescriber MUST submit chart notes that indicate the patient's weight-related comorbid condition(s). (ACTION REQUIRED: Submit supporting documentation.)
[If Yes, then go to 10. If No, then no further questions.]

Yes

No

7

Did the patient have a baseline body mass index (BMI) of 30 kg/m2 to less than 35 kg/m2 at the start of drug therapy for weight loss? [If the patient transitioned from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy when answering this question.] ACTION REQUIRED: If yes, then prescriber MUST submit chart notes that show the patient's baseline BMI. (ACTION REQUIRED: Submit supporting documentation.)
[If Yes, then go to 10. If No, then go to 8.]

Yes

No

8

Did the patient have a baseline body mass index (BMI) of 35 kg/m2 to less than 40 kg/m2 at the start of drug therapy for weight loss? [If the patient transitioned from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy when answering this question.] ACTION REQUIRED: If yes, then prescriber MUST submit chart notes that show the patient's baseline BMI. (ACTION REQUIRED: Submit supporting documentation.)
[If Yes, then go to 10. If No, then go to 9.]

Yes

No

9

Did the patient have a baseline body mass index (BMI) of 40 kg/m2 or greater at the start of drug therapy for weight loss? [If the patient transitioned from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy when answering this question.] ACTION REQUIRED: If yes, then prescriber MUST submit chart notes that show the patient's baseline BMI. (ACTION REQUIRED: Submit supporting documentation.)
[If Yes, then go to 10. If No, then no further questions.]

Yes

No

10

Has the patient lost at least 5 percent of baseline body weight OR has the patient continued to maintain their initial 5 percent weight loss? ACTION REQUIRED: If yes, then documentation is required for approval. Document the patient's weight prior to starting drug therapy for weight loss and the patient's current weight, including the dates the weights were taken: ____________________________
[If Yes, then go to 11. If No, then no further questions.]

Yes

No

11

Does the patient require MORE than the plan allowance per month of any of the following: A) 4 prefilled single-dose pens of Wegovy (semaglutide) or Wegovy HD 7.2 mg (semaglutide), B) 4 prefilled single-dose syringes of Wegovy (semaglutide), C) 1 single-patient-use Wegovy FlexTouch (semaglutide) pen, D) 30 tablets of Wegovy (semaglutide)?
[If Yes, then no further questions. If No, then no further questions.]

Technician Note & RPh Note: If yes, then deny and enter a partial approval per Quantity Limit Chart.

Yes

No

12

Has the patient 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?
[If Yes, then go to 13. If No, then no further questions.]

Yes

No

13

Does the patient have a baseline body mass index (BMI) of less than 27 kg/m2? [If the patient is transitioning from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy when answering this question.]
[If Yes, then no further questions. If No, then go to 14.]

Yes

No

14

Does the patient have a baseline body mass index (BMI) of 27 kg/m2 to less than 30 kg/m2? [If the patient is transitioning from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy when answering this question.] ACTION REQUIRED: If yes, then prescriber MUST submit chart notes that show the patient's baseline BMI. (ACTION REQUIRED: Submit supporting documentation.)
[If Yes, then go to 15. If No, then go to 16.]

Yes

No

15

Does the patient have at least ONE of the following weight-related comorbid conditions: hypertension, dyslipidemia, type 2 diabetes mellitus, obstructive sleep apnea, cardiovascular disease, metabolic dysfunction-associated steatohepatitis (MASH), metabolic dysfunction-associated steatotic liver disease (MASLD), prediabetes, chronic kidney disease stage 2 or higher, osteoarthritis of the knee and/or hip? [If the patient is transitioning from another drug therapy for weight loss, please consider their weight-related comorbid condition(s) at the start of any drug therapy when answering this question.] ACTION REQUIRED: If yes, then prescriber MUST submit chart notes that indicate the patient's weight-related comorbid condition(s). (ACTION REQUIRED: Submit supporting documentation.)
[If Yes, then go to 19. If No, then no further questions.]

Yes

No

16

Does the patient have a baseline body mass index (BMI) of 30 kg/m2 to less than 35 kg/m2? [If the patient is transitioning from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy when answering this question.] ACTION REQUIRED: If yes, then prescriber MUST submit chart notes that show the patient's baseline BMI. (ACTION REQUIRED: Submit supporting documentation.)
[If Yes, then go to 19. If No, then go to 17.]

Yes

No

17

Does the patient have a baseline body mass index (BMI) of 35 kg/m2 to less than 40 kg/m2? [If the patient is transitioning from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy when answering this question.] ACTION REQUIRED: If yes, then prescriber MUST submit chart notes that show the patient's baseline BMI. (ACTION REQUIRED: Submit supporting documentation.)
[If Yes, then go to 19. If No, then go to 18.]

Yes

No

18

Does the patient have a baseline body mass index (BMI) of 40 kg/m2 or greater? [If the patient is transitioning from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy when answering this question.] ACTION REQUIRED: If yes, then prescriber MUST submit chart notes that show the patient's baseline BMI. (ACTION REQUIRED: Submit supporting documentation.)
[If Yes, then go to 19. If No, then no further questions.]

Yes

No

19

Is this request for Wegovy (semaglutide) injection?
[If Yes, then go to 20. If No, then go to 21.]

Yes

No

20

Does the patient require MORE than the plan allowance of any of the following per month: A) 4 prefilled single-dose pens of Wegovy (semaglutide) or Wegovy HD 7.2 mg (semaglutide), B) 4 prefilled single-dose syringes of Wegovy (semaglutide), C) 1 single-patient-use Wegovy FlexTouch (semaglutide) pen?
[If Yes, then no further questions. If No, then no further questions.]

Technician Note & RPh Note: If yes, then deny and enter a partial approval per Quantity Limit Chart.

Yes

No

21

Does the patient require MORE than the plan allowance of 30 tablets per month of Wegovy (semaglutide)?
[If Yes, then no further questions. If No, then no further questions.]

Technician Note & RPh Note: If yes, then deny and enter a partial approval per Quantity Limit Chart.

Yes

No

22

Is the patient 12 to 17 years of age?
[If Yes, then go to 23. If No, then no further questions.]

Yes

No

23

Is this request for ANY of the following: A) Wegovy HD 7.2 mg (semaglutide) injection, B) Wegovy (semaglutide) tablets?
[If Yes, then no further questions. If No, then go to 24.]

Yes

No

24

Is the request for continuation of therapy for a patient that has successfully titrated to a stable maintenance dose? [If the patient is transitioning from another drug therapy for weight loss, please answer no and proceed.]
[If Yes, then go to 25. If No, then go to 28.]

Yes

No

25

Did the patient have a baseline body mass index (BMI) in the 95th percentile or greater standardized for age and sex (obesity) at the start of drug therapy for weight loss? [If the patient is transitioning from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy when answering this question.] ACTION REQUIRED: If yes, then prescriber MUST submit chart notes that indicate the patient's baseline BMI percentile standardized for age and sex. (ACTION REQUIRED: Submit supporting documentation.)
[If Yes, then go to 26. If No, then no further questions.]

Yes

No

26

Has the patient had a reduction from their baseline body mass index (BMI) OR has the patient continued to maintain their initial BMI reduction? ACTION REQUIRED: If yes, then documentation is required for approval. Document the patient's BMI prior to starting drug therapy for weight loss and the patient's current BMI, including the dates the BMIs were taken: ____________________________
[If Yes, then go to 27. If No, then no further questions.]

Yes

No

27

Does the patient require MORE than the plan allowance per month of any of the following: A) 4 prefilled single-dose pens of Wegovy (semaglutide) [excluding Wegovy HD], B) 4 prefilled single-dose syringes of Wegovy (semaglutide), C) 1 single-patient-use Wegovy FlexTouch (semaglutide) pen?
[If Yes, then no further questions. If No, then no further questions.]

Technician Note & RPh Note: If yes, then deny and enter a partial approval per Quantity Limit Chart.

Yes

No

28

Has the patient 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?
[If Yes, then go to 29. If No, then no further questions.]

Yes

No

29

Does the patient have a baseline body mass index (BMI) in the 95th percentile or greater standardized for age and sex (obesity)? [If the patient is transitioning from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy when answering this question.] ACTION REQUIRED: If yes, then prescriber MUST submit chart notes that show the patient's baseline BMI percentile standardized for age and sex. (ACTION REQUIRED: Submit supporting documentation.)
[If Yes, then go to 30. If No, then no further questions.]

Yes

No

30

Does the patient require MORE than the plan allowance per month of any of the following: A) 4 prefilled single-dose pens of Wegovy (semaglutide) [excluding Wegovy HD], B) 4 prefilled single-dose syringes of Wegovy (semaglutide), C) 1 single-patient-use Wegovy FlexTouch (semaglutide) pen?
[If Yes, then no further questions. If No, then no further questions.]

Technician Note & RPh Note: If yes, then deny and enter a partial approval per Quantity Limit Chart.

Yes

No

31

Will the requested drug be used to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in an adult with established cardiovascular disease AND either obesity or overweight?
[If Yes, then go to 32. If No, then go to 42.]

Yes

No

32

Is the requested drug being used with a reduced-calorie diet AND increased physical activity?
[If Yes, then go to 33. If No, then no further questions.]

Yes

No

33

Is this request for Wegovy HD 7.2 mg (semaglutide) injection?
[If Yes, then no further questions. If No, then go to 34.]

Yes

No

34

Does the patient have established cardiovascular disease with a history of ONE of the following: A) previous myocardial infarction (MI), B) previous stroke, C) symptomatic peripheral arterial disease (PAD), as evidenced by intermittent claudication with ankle-brachial index (ABI) less than 0.85 (at rest), peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease, D) prior history of revascularization (coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or angioplasty)? ACTION REQUIRED: If yes, then prescriber MUST submit chart notes supporting the patient's diagnosis, including diagnostic evidence, of at least one of the above conditions. (ACTION REQUIRED: Submit supporting documentation.)
[If Yes, then go to 35. If No, then no further questions.]

Yes

No

35

Is this request for continuation of therapy?
[If Yes, then go to 36. If No, then go to 38.]

Yes

No

36

Is the patient being treated with a maintenance dosage of the requested drug which is based on individual treatment response and tolerability?
[If Yes, then go to 37. If No, then no further questions.]

Yes

No

37

Does the patient require MORE than the plan allowance per month of any of the following: A) 4 prefilled single-dose pens of Wegovy (semaglutide) [excluding Wegovy HD], B) 4 prefilled single-dose syringes of Wegovy (semaglutide), C) 1 single-patient-use Wegovy FlexTouch (semaglutide) pen, D) 30 tablets of Wegovy (semaglutide)?
[If Yes, then no further questions. If No, then no further questions.]

Technician Note & RPh Note: If yes, then deny and enter a partial approval per Quantity Limit Chart.

Yes

No

38

Does the patient have a baseline body mass index (BMI) greater than or equal to 27 kg/m2? [If the patient is transitioning from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy when answering this question.] ACTION REQUIRED: If yes, then prescriber MUST submit chart notes that show the patient's baseline BMI. (ACTION REQUIRED: Submit supporting documentation.)
[If Yes, then go to 39. If No, then no further questions.]

Yes

No

39

Does the patient have type 2 diabetes? [Ozempic is indicated to reduce the risk of major cardiovascular events in adults with type 2 diabetes mellitus and established cardiovascular disease. Patients with type 2 diabetes may be treated for risk reduction of cardiovascular events with Ozempic. If the patient may be treated with Ozempic, please provide the patient with a new prescription for Ozempic.]
[If Yes, then no further questions. If No, then go to 40.]

Yes

No

40

Is the patient currently receiving guideline-directed management and therapy (GDMT) for cardiovascular disease (e.g., lipid-lowering agent, antiplatelet, beta-blocker, renin-angiotensin inhibitor, etc.) OR does the patient have a clinical reason not to be treated with GDMT for cardiovascular disease? ACTION REQUIRED: If yes, then prescriber MUST submit chart notes showing that the patient is currently receiving GDMT for cardiovascular disease or showing the clinical reason why the patient cannot be treated with GDMT for cardiovascular disease (e.g., intolerance, contraindication, allergy). (ACTION REQUIRED: Submit supporting documentation.)
[If Yes, then go to 41. If No, then no further questions.]

Yes

No

41

Does the patient require MORE than the plan allowance per month of any of the following: A) 4 prefilled single-dose pens of Wegovy (semaglutide) [excluding Wegovy HD], B) 4 prefilled single-dose syringes of Wegovy (semaglutide), C) 1 single-patient-use Wegovy FlexTouch (semaglutide) pen, D) 30 tablets of Wegovy (semaglutide)?
[If Yes, then no further questions. If No, then no further questions.]

Yes

No

42

Is the requested drug being prescribed for the treatment of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH), formerly known as nonalcoholic steatohepatitis (NASH), with moderate to advanced liver fibrosis (consistent with stages F2 to F3 fibrosis) in an adult?
[If Yes, then go to 43. If No, then no further questions.]

Yes

No

43

Is the requested drug being used with a reduced-calorie diet AND increased physical activity?
[If Yes, then go to 44. If No, then no further questions.]

Yes

No

44

Is this request for ANY of the following: A) Wegovy HD 7.2 mg (semaglutide) injection, B) Wegovy (semaglutide) tablets?
[If Yes, then no further questions. If No, then go to 45.]

Yes

No

45

Is this request for continuation of therapy?
[If Yes, then go to 46. If No, then go to 49.]

Yes

No

46

Has the patient achieved or maintained a positive clinical response to the requested drug (e.g., improvement in liver function such as reduction in alanine aminotransferase [ALT], improvement in enhanced liver fibrosis [ELF] score, improvement in liver stiffness measurement [LSM] by ultrasound-based elastography, magnetic resonance elastography [MRE])? ACTION REQUIRED: If yes, then prescriber MUST submit chart notes or other documentation supporting that the patient achieved or maintained a positive clinical response to the requested drug. (ACTION REQUIRED: Submit supporting documentation.)
[If Yes, then go to 47. If No, then no further questions.]

Yes

No

47

Is the patient being treated with a maintenance dosage of the requested drug which is based on individual treatment response and tolerability?
[If Yes, then go to 48. If No, then no further questions.]

Yes

No

48

Does the patient require MORE than the plan allowance per month of any of the following: A) 4 prefilled single-dose pens of Wegovy (semaglutide) [excluding Wegovy HD], B) 4 prefilled single-dose syringes of Wegovy (semaglutide), C) 1 single-patient-use Wegovy FlexTouch (semaglutide) pen?
[If Yes, then no further questions. If No, then no further questions.]

Technician Note & RPh Note: If yes, then deny and enter a partial approval per Quantity Limit Chart.

Yes

No

49

Is the requested drug being prescribed by, or in consultation with, a gastroenterologist or hepatologist?
[If Yes, then go to 50. If No, then no further questions.]

Yes

No

50

Has the patient's moderate to advanced liver fibrosis (consistent with stages F2 to F3 fibrosis) at baseline been confirmed by ONE of the following: non-invasive liver disease assessment (e.g., ultrasound-based elastography, magnetic resonance elastography [MRE], enhanced liver fibrosis [ELF] score) OR historical liver biopsy? ACTION REQUIRED: If yes, then prescriber MUST submit chart notes or other documentation supporting that the patient's moderate to advanced liver fibrosis (consistent with stages F2 to F3 fibrosis) at baseline has been confirmed by non-invasive liver disease assessment (ultrasound-based elastography, MRE, ELF score) OR historical liver biopsy. (ACTION REQUIRED: Submit supporting documentation.)
[If Yes, then go to 51. If No, then no further questions.]

Yes

No

51

Does the patient require MORE than the plan allowance per month of any of the following: A) 4 prefilled single-dose pens of Wegovy (semaglutide) [excluding Wegovy HD], B) 4 prefilled single-dose syringes of Wegovy (semaglutide), C) 1 single-patient-use Wegovy FlexTouch (semaglutide) pen?
[If Yes, then no further questions. If No, then no further questions.]

Technician Note & RPh Note: If yes, then deny and enter a partial approval per Quantity Limit Chart.

Yes

No

Mapping Instructions

Yes

No

DENIAL REASONS

1.

Go to 2

Go to 31

2.

Go to 3

Go to 22

3.

Go to 4

Go to 12

4.

Deny

Go to 5

Your plan only covers this drug when it is used for certain health conditions. Covered uses are when you have: A) An initial body mass index (BMI) of at least 30 kg/m2 at the start of drug therapy for weight loss, or B) An initial BMI of 27 kg/m2 to less than 30 kg/m2 with one or more weight-related health conditions at the start of drug therapy for weight loss. Your plan does not cover this drug for your health condition that your doctor told us you have. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: Continuation, WL Diagnosis - adult]

5.

Go to 6

Go to 7

6.

Go to 10

Deny

Your plan only covers this drug when it is used for certain health conditions and when records with your health condition(s) at the start of drug therapy for weight loss are sent to us. Covered uses are when you have: A) An initial body mass index (BMI) of at least 30 kg/m2, or B) An initial BMI of 27 kg/m2 to less than 30 kg/m2 with one or more weight-related health conditions. Your records must be provided and must show what your doctor told us.  We denied your request because your plan does not cover this drug for your health condition that your doctor told us you have, we did not receive your records, or the records did not show what your doctor told us. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: Continuation, Weight Loss Diagnosis, Adult with comorbidity documentation]

7.

Go to 10

Go to 8

8.

Go to 10

Go to 9

9.

Go to 10

Deny

Your plan only covers this drug when it is used for certain health conditions, and when records with your initial body mass index (BMI) at the start of drug therapy for weight loss are sent to us. Covered uses are when you have: A) An initial body mass index (BMI) of at least 30 kg/m2, or B) An initial BMI of 27 kg/m2 to less than 30 kg/m2 with one or more weight-related health conditions. Your records must be provided and must show what your doctor tells us. We denied your request because your plan does not cover this drug for your health condition that your doctor told us you have, we did not receive your records, or the records did not show the initial body mass index (BMI) your doctor told us. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: Continuation, Weight Loss Diagnosis, Adult with initial BMI documentation]

10.

Go to 11

Deny

Your plan only covers this drug when you experience benefits from taking the drug and when your results from taking the drug are sent to us. Your doctor needs to send us all of the following: A) Your weight prior to starting weight loss drug therapy, B) Your weight now, and C) The dates your weights were taken. We have denied your request because you did not have good outcomes from the drug or because we did not receive all of your results. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: Continuation: Efficacy, Positive Response, Stable or Not worsening, Lab/test with documentation]

11.

Deny, Please select appropriate denial close option. For the denial verbiage, only include the requested drug. Remove all other drugs from verbiage.

Approve, 12 Months, PA approved for 12 months. See Quantity Limit Chart.

We have denied your request because it is for more than the amount your plan covers (quantity limit). We reviewed the information we had. We have partially approved your request for this drug up to the amount your plan covers per month (1 package of 4 prefilled single-dose pens or syringes of Wegovy injection, 1 single-patient-use Wegovy FlexTouch pen, OR 30 tablets of Wegovy). Your request for more drug has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: Quantity, Exceeds max limit, Partial denial – Wegovy injection/tablet]

12.

Go to 13

Deny

Your plan only covers this drug if you have been in a comprehensive weight management program for at least 6 months before starting this drug. We have denied your request because you have not been taking part in a comprehensive weight management program for at least 6 months. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: No comprehensive weight management program]

13.

Deny

Go to 14

Your plan only covers this drug when it is used for certain health conditions. Covered uses are when you have: A) An initial body mass index (BMI) of at least 30 kg/m2, or B) An initial BMI of 27 kg/m2 to less than 30 kg/m2 with one or more weight-related health conditions. Your plan does not cover this drug for your health condition that your doctor told us you have. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: WL Diagnosis - adult]

14.

Go to 15

Go to 16

15.

Go to 19

Deny

Your plan only covers this drug when it is used for certain health conditions and when records with your health condition(s) are sent to us. Covered uses are when you have: A) An initial body mass index (BMI) of at least 30 kg/m2, or B) An initial BMI of 27 kg/m2 to less than 30 kg/m2 with one or more weight-related health conditions. Your records must be provided and must show what your doctor told us.  We denied your request because your plan does not cover this drug for your health condition that your doctor told us you have, we did not receive your records, or the records did not show what your doctor told us. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: Adult - WL Diagnosis - Comorbidity w/  Documentation]

16.

Go to 19

Go to 17

17.

Go to 19

Go to 18

18.

Go to 19

Deny

Your plan only covers this drug when it is used for certain health conditions, and when records with your initial body mass index (BMI) are sent to us. Covered uses are when you have: A) An initial body mass index (BMI) of at least 30 kg/m2, or B) An initial BMI of 27 kg/m2 to less than 30 kg/m2 with one or more weight-related health conditions. Your records must be provided and must show what your doctor tells us. We denied your request because your plan does not cover this drug for your health condition that your doctor told us you have, we did not receive your records, or the records did not show the initial body mass index (BMI) your doctor told us. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: WL Diagnosis – Adult - initial BMI documentation]

19.

Go to 20

Go to 21

20.

Deny

Approve, 8 Months, PA approved for 8 months. See Quantity Limit Chart.

We have denied your request because it is for more than the amount your plan covers (quantity limit). We reviewed the information we had. We have partially approved your request for this drug up to the amount your plan covers per month (1 package of 4 prefilled single-dose pens or syringes of Wegovy injection, OR 1 single-patient-use Wegovy FlexTouch pen). Your request for more drug has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: Quantity, Exceeds max limit, Partial denial - Wegovy injection]

21.

Deny

Approve, 6 Months, PA approved for 6 months. See Quantity Limit Chart.

We have denied your request because it is for more than the amount your plan covers (quantity limit). We reviewed the information we had. We have partially approved your request for this drug up to the amount your plan covers (30 tablets per month). Your request for more drug has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: Quantity, Exceeds max limit, Partial denial – Wegovy tablet]

22.

Go to 23

Deny

Your plan only covers this drug if you are 12 years old or older. We reviewed the information we had. Your request has been denied. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: Age]

23.

Deny

Go to 24

We have denied your request because your plan does not cover this drug formulation or strength for weight loss in kids. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: WM Exclusion, Wegovy HD/tablets in Peds]

24.

Go to 25

Go to 28

25.

Go to 26

Deny

Your plan only covers this drug when it is used for certain health conditions and when your health records with your health condition(s) at the start of drug therapy are sent to us. Covered use is when you have an initial body mass index (BMI) in the 95th percentile or greater standardized for age and sex. Your records must be provided and must show what your doctor told us. We denied your request because your plan does not cover this drug for your health condition that your doctor told us you have we did not receive your records, or the records did not show what your doctor told us. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: WL Diagnosis - pediatrics - initial BMI documentation]

26.

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Deny

Your plan only covers this drug when you experience benefits from taking the drug and when your results from taking the drug are sent to us. Your doctor needs to send us all of the following: A) Your body mass index (BMI) prior to starting weight loss drug therapy, B) Your BMI now, and C) The dates your BMIs were taken. We have denied your request because you did not have good outcomes from the drug or because we did not receive all of your results. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: Efficacy, Positive Response, Stable or Not worsening, Lab/test for BMI with documentation]

27.

Deny

Approve, 12 Months, PA approved for 12 months. See Quantity Limit Chart.

We have denied your request because it is for more than the amount your plan covers (quantity limit). We reviewed the information we had. We have partially approved your request for this drug up to the amount your plan covers per month (1 package of 4 prefilled single-dose pens or syringes of Wegovy injection [excluding Wegovy HD], OR 1 single-patient-use Wegovy FlexTouch pen). Your request for more drug has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: Quantity, Exceeds max limit, Partial denial - Wegovy injection, excluding Wegovy HD]

28.

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Deny

Your plan only covers this drug if you have been in a comprehensive weight management program for at least 6 months before starting this drug. We have denied your request because you have not been taking part in a comprehensive weight management program for at least 6 months. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: No comprehensive weight management program]

29.

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Deny

Your plan only covers this drug when it is used for certain health conditions and when your health records with your health condition(s) at the start of drug therapy are sent to us. Covered use is when you have an initial body mass index (BMI) in the 95th percentile or greater standardized for age and sex. Your records must be provided and must show what your doctor told us. We denied your request because your plan does not cover this drug for your health condition that your doctor told us you have we did not receive your records, or the records did not show what your doctor told us. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: WL Diagnosis - pediatrics - initial BMI documentation]

30.

Deny

Approve, 7 Months, PA approved for 7 months. See Quantity Limit Chart.

We have denied your request because it is for more than the amount your plan covers (quantity limit). We reviewed the information we had. We have partially approved your request for this drug up to the amount your plan covers per month (1 package of 4 prefilled single-dose pens or syringes of Wegovy injection [excluding Wegovy HD], OR 1 single-patient-use Wegovy FlexTouch pen). Your request for more drug has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: Quantity, Exceeds max limit, Partial denial - Wegovy injection, excluding Wegovy HD]

31.

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32.

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Deny

Your plan only covers this drug if you will be taking it as a part of a healthy living plan supported by the FDA (United States Food and Drug Administration). We have denied your request because you must be on a low calorie diet and do physical activity while taking this drug. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: Not used with lifestyle modification per indication]

33.

Deny

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We have denied your request because your plan does not cover this drug formulation and strength to decrease risk of heart events in obese or overweight adults. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: CVD, Exclusion, Wegovy HD]

34.

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Deny

Your plan only covers this drug to decrease risk of heart events when you have a history of certain health conditions or certain medical procedures, and when records with your history of heart conditions are sent to us. Those health conditions are heart attack, stroke, peripheral artery disease (PAD) with symptoms, and ischemic cardiomyopathy. Those medical procedures are coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), angioplasty, and positive nuclear stress test. Your plan does not cover this drug for your history that your doctor told us you have. We denied your request because you do not have a prior heart attack, prior stroke, PAD with symptoms, ischemic cardiomyopathy, CABG, PCI, angioplasty, or positive nuclear stress test. Your records must be provided and must show what your doctor tells us. We denied your request because your plan does not cover this drug for your health condition that your doctor told us you have, we did not receive your records, or the records did not show what your doctor has told us. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: CVD, Diagnosis of established disease with Disease Documentation]

35.

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36.

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Deny

Your plan only continues to cover this drug when you are taking a maintenance dose of this drug. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: Maintenance dosing]

37.

Deny, Please select appropriate denial close option. For the denial verbiage, only include the requested drug. Remove all other drugs from verbiage.

Approve, 12 Months, PA approved for 12 months. See Quantity Limit Chart.

We have denied your request because it is for more than the amount your plan covers (quantity limit). We reviewed the information we had. We have partially approved your request for this drug up to the amount your plan covers per month (1 package of 4 prefilled single-dose pens or syringes of Wegovy injection [excluding Wegovy HD], 1 single-patient-use Wegovy FlexTouch pen, OR 30 tablets of Wegovy). Your request for more drug has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: Quantity, Exceeds max limit, Partial denial – Wegovy injection/tablet, excluding Wegovy HD]

38.

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Deny

Your plan only covers this drug to decrease risk of heart events if your initial body mass index (BMI) is 27 kg/m2 or higher, and when records of your initial body mass index (BMI) are sent to us. Your records must be provided and must show what your doctor tells us. We denied your request because your plan does not cover this drug for your health condition that your doctor told us you have, we did not receive your records, or the records did not show the initial body mass index (BMI) your doctor told us. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: CVD, Exclusion for BMI with Initial BMI Documentation]

39.

Deny

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Your plan only covers this drug when you have known heart disease and are using it to decrease risk of heart events, you are obese or overweight, and you do not have type 2 diabetes. Your plan may cover a similar drug when you have diabetes. You may be able to be treated with a similar drug for your health condition. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: Exclusion for diabetes]

40.

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Deny

Your plan only covers this drug to decrease risk of heart events if you will be taking it with other drugs, and, when records with the drugs you are taking for heart disease, or records telling us why you cannot take drugs for heart disease, are sent to us. Your records must be provided and must show what your doctor tells us. We have denied your request because: A) You are not (or will not be) taking other drugs to treat heart disease (for example, antiplatelets, cholesterol drugs, beta-blockers, or renin-angiotensin inhibitors), B) You do not have a medical reason not to take them, or C) We did not receive your records or the records did not show what your doctor has told us . We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: CVD, No concurrent GDMT with Documentation]

41.

Deny, Please select appropriate denial close option. For the denial verbiage, only include the requested drug. Remove all other drugs from verbiage.

Approve, 12 Months, PA approved for 12 months. See Quantity Limit Chart.

We have denied your request because it is for more than the amount your plan covers (quantity limit). We reviewed the information we had. We have partially approved your request for this drug up to the amount your plan covers per month (1 package of 4 prefilled single-dose pens or syringes of Wegovy injection [excluding Wegovy HD], 1 single-patient-use Wegovy FlexTouch pen, OR 30 tablets of Wegovy). Your request for more drug has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: Quantity, Exceeds max limit, Partial denial – Wegovy injection/tablet, excluding Wegovy HD]

42.

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Deny

Your plan only covers this drug when it is used for certain health conditions as part of a healthy living plan supported by the FDA (United States Food and Drug Administration). Covered uses are to A) Decrease body weight in obese or overweight adults, B) Decrease body weight in obese children for Wegovy injection (except Wegovy HD), C) Maintain weight loss long term in obese or overweight adults, D) Maintain weight loss long term in obese children for Wegovy injection (except Wegovy HD), E) Decrease risk of heart events in obese or overweight adults (except Wegovy HD), F) Treat noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH), also known as nonalcoholic steatohepatitis (NASH), with moderate to advanced liver fibrosis in adults for Wegovy injection (except Wegovy HD). When using this drug for these health conditions, you must be on a low calorie diet and do physical activity. Your plan does not cover this drug for your health condition that your doctor told us you have, or you will not be on a low calorie diet and doing physical activity while taking this drug. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: Diagnosis - per indication]

43.

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Deny

Your plan only covers this drug if you will be taking it as a part of a healthy living plan supported by the FDA (United States Food and Drug Administration). We have denied your request because you must be on a low calorie diet and do physical activity while taking this drug. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: Not used with lifestyle modification per indication]

44.

Deny

Go to 45

We have denied your request because your plan does not cover this drug formulation or strength for the treatment of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH), formerly known as nonalcoholic steatohepatitis (NASH), with moderate to advanced liver fibrosis in an adult. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: MASH Exclusion, Wegovy HD/tablets]

45.

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Go to 49

46.

Go to 47

Deny

Your plan only covers this drug if it works well for you and when records showing it works well for you are sent to us. Your records must be provided and must show what your doctor tells us. We denied your request because we did not receive your records or the records did not show what your doctor has told us. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: MASH, Continuation: Efficacy Documentation]

47.

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Deny

Your plan only continues to cover this drug when you are taking a maintenance dose of this drug. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: Maintenance dosing]

48.

Deny

Approve, 12 Months, PA approved for 12 months. See Quantity Limit Chart

We have denied your request because it is for more than the amount your plan covers (quantity limit). We reviewed the information we had. We have partially approved your request for this drug up to the amount your plan covers per month (1 package of 4 prefilled single-dose pens or syringes of Wegovy injection [excluding Wegovy HD], OR 1 single-patient-use Wegovy FlexTouch pen). Your request for more drug has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: Quantity, Exceeds max limit, Partial denial - Wegovy injection, excluding Wegovy HD]

49.

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Deny

Your plan only covers this drug if your doctor is a gastroenterologist or hepatologist or has talked about your care plan with a gastroenterologist or hepatologist. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: Prescriber specialty - MASH]

50.

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Deny

Your plan only covers this drug when you have stage F2 to F3 liver fibrosis confirmed by non-invasive liver disease assessment (for example, ultrasound-based elastography, magnetic resonance elastography [MRE], enhanced liver fibrosis [ELF] score), or historical liver biopsy. We denied your request because we did not receive your results, or your test result did not show you had F2 to F3 liver fibrosis. We reviewed the information we had. Your request has been denied. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: MASH Lab/Test w/ Documentation]

51.

Deny

Approve, 12 Months, PA approved for 12 months. See Quantity Limit Chart

We have denied your request because it is for more than the amount your plan covers (quantity limit). We reviewed the information we had. We have partially approved your request for this drug up to the amount your plan covers per month (1 package of 4 prefilled single-dose pens or syringes of Wegovy injection, OR 1 single-patient-use Wegovy FlexTouch pen). Your request for more drug has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.

[Short Description: Quantity, Exceeds max limit, Partial denial - Wegovy injection]