CurrentHighmark Blueshield NenyPolicy N/A

Medication prior authorization for Qsymia and other weight-loss medications

This form and policy govern prior authorization submission requirements for weight-loss medications (example: Qsymia) for Highmark BlueShield members in North Carolina, detailing required member, provider, medication, and clinical documentation to obtain authorization.

Policy Summary

PayerHighmark Blueshield Neny

PolicyMedication prior authorization for Qsymia and other weight-loss medications

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed Medication Prior Authorization Form (one per medication) with all required member, provider, medication, and clinical information and fax to 1-866-240-8123.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1-866-240-8123fax number to submit form

1separate form required per medication

30/90day supply options

Qsymiaexample medication referenced

Coverage Criteria

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Authorization criteria

Covered when ALL of the following are met

Completed form: A separate, fully completed Medication Prior Authorization Form is submitted for each medication, including member, provider, medication, and clinical information.

See submission instructions and fax number on form (fax to 1-866-240-8123 or mail as indicated).

Lifestyle modification documentation: Provider supplies documentation that the member engaged in a lifestyle modification program encouraging reduced calorie diet and increased physical activity; at least one acceptable form of documentation from the Diet category and one from the Physical Activity category are required.duration in months specified by provider

Acceptable diet documentation: provider chart notes, recurring program receipts (e.g., Noom, Weight Watchers), dietary logs, or recurring nutrition counseling receipts. Acceptable physical activity documentation: provider chart notes, recurring gym membership receipts, wearable device activity summary, or recurring personal trainer receipts.

Clinical baseline and comorbidity documentation: Provider attaches baseline (pre-therapy) and, if applicable, current height, weight, and BMI, documents any weight-related comorbidities, and lists prior weight-loss medication trials with dates.

Attach supporting chart notes or other clinical documentation showing baseline and current measurements, comorbidity evidence, and prior medication trial dates.

The form itself does not list explicit coverage criteria on the face of the document. Instead, authorization is contingent on submission of a separate, fully completed Medication Prior Authorization Form for each medication along with the required supporting clinical documentation as described on the form (see submission instructions and fax number).

The form does not specify discrete conditions that are labeled "Not Medically Necessary." No explicit Not Medically Necessary criteria are provided on this document; determinations would be based on the absence of required information or supporting documentation when reviewing the prior authorization request.

Coding

Codes mentioned in formmixed

N/A	No explicit CPT/HCPCS/ICD-10/NDC codes listed on form

Program participation duration requirements

Program participation durationProvider must specify number of months the member actively participated in a lifestyle modification program prior to initiating therapy (entry asks: 'Please specify how long (in months) this member has actively participated...'),

Documentation cadenceAcceptable evidence includes recurring receipts or monthly documentation (e.g., monthly receipts for commercial programs or monthly nutrition counseling) to substantiate participation over the specified months.

PurposeDuration documents prior engagement in reduced-calorie diet and increased physical activity required before and/or during pharmacotherapy.

Provider Actions and Submission Requirements

Denial Risk

Missing documentation may trigger denial

Missing required documentation may result in denial of the prior authorization request. Provide all requested clinical records, lifestyle program documentation, prior-therapy details, and completed forms to avoid processing delays or denial.

Failure to provide documentation such as lifestyle program participation records, chart notes, receipts, or prior-therapy dates may trigger denial
Ensure completed Medication Prior Authorization Form is submitted (one form per medication)
Attach all clinical notes and supporting documentation before submission

Documentation Required

Required lifestyle modification documentation

Attach documentation that the member actively participated in a lifestyle modification program that includes both a reduced-calorie diet and increased physical activity. One item from each category (Diet and Physical Activity) is required as evidence.

Diet: provider chart notes detailing dietary adjustments or calorie deficit; recurring receipts for subscriptions to structured programs (e.g., Noom, Weight Watchers, Omada) provided monthly; member dietary logs; recurring appointments/receipts for nutritional counseling or medical nutrition therapy
Physical activity: provider chart notes specifying type, duration, and frequency; recurring gym membership receipts with activity notes; wearable device summary reports showing activity frequency/duration; recurring personal trainer appointment receipts with activity notes

Documentation Required

Clinical and prior-therapy documentation

Provide clinical documentation demonstrating weight-related comorbidities, prior medication trials (with specific medication names and dates), and baseline and current anthropometric data. Attach chart notes or other supporting records for each item.

List and attach documentation of weight-related comorbidities (e.g., hypertension, diabetes, OSA) with supporting chart notes
Prior medication trials: provide names of prior weight-loss medications tried and failed (e.g., Zepbound, prior Qsymia therapy) with exact dates of therapy
Baseline and current measurements: height, weight, and BMI prior to initiating therapy and current values while on therapy (attach chart notes)

Prior Authorization

Prior medication trials

Provide a complete history of prior weight-loss medications tried and why they were discontinued or considered unsuccessful; include therapy start and end dates.

List previous weight-loss medications (e.g., specific drug names) and reason for failure or discontinuation
Include precise dates of therapy for each prior medication

Background

This prior authorization form applies to pharmacologic weight-loss therapy (example: Qsymia) and is intended to document clinical justification before coverage is authorized. The form requires evidence that the member has engaged in a lifestyle modification program encouraging reduced-calorie diet and increased physical activity, and it requests baseline and current anthropometrics and comorbidity information. Providers must submit a separate, fully completed form for each medication and include all required clinical documentation when faxing or mailing the request to the address or fax number provided on the form.

Definitions

Lifestyle modification program — definition and acceptable examples

DefinitionA lifestyle modification program encourages reduced calorie diet and increased physical activity and may include nutritional counseling, participation in comprehensive weight-management programs, or other documented diet and exercise interventions.

Diet examplesProvider chart notes detailing dietary adjustments, member dietary logs, recurring receipts for programs (e.g., Noom, Weight Watchers, Vida, Lark, Signos, Wondr, Livongo, Omada, Newtopia, Virta), or recurring nutrition counseling/medical nutrition therapy receipts.

Physical activity examplesProvider chart notes specifying type/duration/frequency of activity, recurring gym membership receipts, wearable device summary reports (e.g., elevated heart rate >20 minutes ≥3×/week for a month), or recurring personal trainer receipts/notes.

Documentation requirementOne form of documentation is required from each category (diet and physical activity) to demonstrate participation.