Prior authorization form for GLP‑1 receptor agonists (Wegovy, Zepbound) — coverage criteria and submission requirements
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This document is a prior authorization request form used by providers to request initiation or continuation of GLP‑1 receptor agonists (notably Wegovy and Zepbound) for indications including cardioprotection, NASH/MASH, and obstructive sleep apnea; it governs submission requirements and clinical information needed for Medicaid pharmacy PA review. Affects prescribing providers and prior authorization reviewers.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Therapy — Wegovy (cardioprotection)
Wegovy for cardioprotection — Covered when ALL of the following are met
Form items 1–7 capture these requirements
Initial Therapy — Wegovy (NASH/MASH)
Wegovy for NASH/MASH — Covered when ALL of the following are met
Form items 1–13 capture these requirements
Initial Therapy — Zepbound (sleep apnea)
Zepbound for obstructive sleep apnea — Covered when ALL of the following are met
Form items 1–9 capture these requirements
Continuation Therapy
Continuation therapy (Wegovy and Zepbound) — Covered when ALL of the following are met
Continuation-specific items from continuation sections
The policy lists specific exclusionary conditions for GLP‑1 receptor agonist use. For Wegovy when requested for NASH/MASH, decompensated cirrhosis and moderate to severe hepatic impairment (Child‑Pugh B or C) are exclusionary and must be absent for coverage (form items ask whether these conditions are present). Pregnancy and lactation, a personal or family history of medullary thyroid carcinoma, and multiple endocrine neoplasia type 2 (MEN2) are also listed as contraindications that exclude use of Zepbound and other GLP‑1 agents. Additionally, requests for Zepbound must confirm absence of FDA‑labeled contraindications (including pregnancy, lactation, history of medullary thyroid cancer, MEN2) per the form.
Providers should ensure other liver diseases and alcohol consumption limits are documented per the NASH/MASH section (form items request other liver disease and alcohol use by sex), since the policy requires noncirrhotic NASH/MASH with appropriate fibrosis staging and testing before Wegovy is approved.
Requests may be delayed or denied if required documentation is missing. The form explicitly asks whether the beneficiary was previously approved through Medicaid PA and notes that beneficiaries without prior approval will require initial evaluation review; absence of that history or supporting documentation can trigger denial. For continuation requests, the form requires submission of medical documentation that the beneficiary has improved on therapy and that individual clinical goals are being met; failure to include evidence of improvement or goal attainment risks a determination of not medically necessary.
The form also requires the provider to attest that the product is prescribed consistent with FDA‑approved indication, age, weight and dosing limits, that ongoing lifestyle modification is documented, and that a medication‑list review for possible dose reductions/discontinuations has been performed. Omission of these attestations or the supporting clinical records may result in an incomplete review or denial.
Initial Therapy — Per Indication
Initial Therapy — per indication
Initial authorization — criteria are specific to the requested indication. Covered when ALL of the indication-specific criteria below are met.
Form items in chunk 4
Form items in chunks 5–6
Form items in chunk 8
Continuation Therapy Requirements
Continuation — Wegovy and Zepbound
Continuation requirements for previously approved beneficiaries — Covered when ALL of the following are met
Continuation form items
Provider Actions and Requirements
Prior Authorization Required
Prior authorization is required for initiation and continuation of therapy. Include any prior approvals and supporting documentation with the request; requests without prior authorization when required are at high risk for denial.
- Include prior approvals and Medicaid PA documentation when applicable
- Attach clinical documentation demonstrating indication-specific criteria were met at initiation and continued response for continuation requests
Denial Risk Triggers
Items that commonly trigger denials: missing prior authorization, insufficient clinical documentation of baseline measures or diagnostic testing, absence of documented improvement or clinical goals for continuation requests, use with another GLP‑1 without justification, and failure to confirm absence of FDA‑labeled contraindications (e.g., personal/family history of medullary thyroid carcinoma or MEN2 where applicable).
- No prior approval on file for agents required to have prior authorization
- Lack of baseline weight/BMI and dates
- Missing diagnostic tests or fibrosis staging for NASH/MASH (liver biopsy, VCTE, ELF, MRE, or FIB‑4 score)
- No documentation of improvement or that individual clinical goals are being met on continuation requests
- Concurrent use with another GLP‑1 without documentation supporting combined use
- No medication list review showing dose adjustments or discontinuations of other therapies when clinically indicated
Required Clinical Documentation
Submit all required clinical documentation to support the indication requested. For cardioprotection include baseline weight/BMI (with dates), age, and documentation of established CVD when applicable. For NASH/MASH include diagnosis, baseline BMI, FIB‑4 score (with value), and results of fibrosis assessment (liver biopsy, VCTE, ELF, or MRE). For sleep apnea include baseline BMI, diagnostic sleep testing documentation, and evidence of moderate–severe OSA when indicated. For continuation requests include prior approval documentation (if previously approved), evidence of clinical improvement, and confirmation that individual treatment goals are being met. Always document review for FDA‑labeled contraindications and medication reconciliation addressing concomitant GLP‑1 use and potential medication dose reductions.
- Baseline weight and BMI with dates
- Age verification where required by indication
- Diagnostic test reports (liver biopsy/VCTE/ELF/MRE) or FIB‑4 score for NASH/MASH
- Sleep study report for obstructive sleep apnea indications
- Documentation of lifestyle modification counseling and ongoing plan
- Provider medication list review and plan for dose adjustments or discontinuations
- Evidence of prior approvals and documentation of clinical improvement for continuation requests
Coding and Key Clinical Thresholds
Step Therapy and Prior Authorization History
| Item | Response |
|---|---|
| Previously approved through Medicaid PA (prior Medicaid approval) | |
| Yes / No — Document whether the beneficiary was previously approved for the requested agent through Medicaid's Prior Authorization process | |
| Medical documentation of improvement on medication included | |
| Yes / No — Attach clinical documentation showing beneficiary has improved while on the medication | |
| Concomitant GLP‑1 use | |
| Yes / No — Indicate whether the beneficiary will be using the requested agent with another GLP‑1 (concomitant use) | |
| Provider medication list review performed | |
| Yes / No — Provider confirmed review of medication list for possible dose reductions or discontinuations of comorbid condition medications |
Definitions and Clinical Terms
Background
This prior authorization form is designed to collect condition‑specific baseline data and screening information to determine appropriateness of GLP‑1 receptor agonist therapy for non‑weight‑loss indications. For NASH/MASH the form requests diagnosis confirmation, fibrosis assessment (FIB‑4 consistent with F1–F3) and objective testing such as liver biopsy, VCTE, ELF score, or MRE, plus baseline BMI and alcohol use limits. For obstructive sleep apnea (Zepbound) the form collects age, confirmation of moderate to severe OSA with obesity, baseline BMI (>40 kg/m2), documentation of sleep apnea testing and instruction on sleep hygiene.
The form also captures items needed for continuation reviews, including prior Medicaid PA status, documentation of clinical improvement and progress toward individualized goals, confirmation that FDA‑labeled contraindications are absent, and that the prescriber has reviewed the medication list for possible dose changes. These data elements support the PA review process and ensure therapy is consistent with indication‑specific requirements and safety screening.
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