CurrentHighmark Blueshield NenyPolicy N/A

Medication Prior Authorization Form for weight-loss medications

A fillable prior authorization (PA) request form used by Highmark BlueShield entities for requesting coverage of a single medication (primarily weight-loss agents/GLP-1 receptor agonists). It collects member, provider, medication, clinical history, documentation attachments, and signature to support PA determination.

Policy Summary

PayerHighmark Blueshield Neny

PolicyMedication Prior Authorization Form for weight-loss medications

Policy CodePolicy N/A

Change TypeInformational form (no coverage change)

Effective Date

Next Review Date

Key ActionProvider must submit a separate prior authorization form for each requested medication and include required documentation; fax to 1-866-240-8123 or mail per form instructions.

POLICY UPDATE CHANGES

No material clinical or coverage changes — this is an informational administrative PA form.

1Form per medication required

2Documentation categories required

1-866-240-8123Fax number for PA submission

Policy Form Overview

This is a fillable prior authorization (PA) request form used by Highmark BlueShield entities to request coverage for a single medication (primarily weight‑loss agents and GLP‑1 receptor agonists). It collects member, provider, medication, clinical history, documentation attachments, and the prescribing provider's signature to support a PA determination.

Documentation & Clinical Information Required for PA

Form requires documentation and answers to ALL applicable questions to support a PA decision for a single medication:

ALL of the following

Administrative details: Submit a separate form for each medication; provide member, provider, and medication information; include provider signature and date; fax or mail completed form as instructed.
See form for required fields (subscriber ID, group number, name, DOB, contact, physician name, NPI, phone, fax, address, drug name, strength, quantity, day supply, directions).
Lifestyle modification questions: Answer whether member will use the medication with a lifestyle modification program (Yes/No) and specify duration (months) of participation prior to initiating therapy.
If yes, documentation required (see Diet and Physical Activity acceptable documentation lists).
Lifestyle documentation required
- Diet acceptable documentation (ONE required)
  - Provider chart notes detailing specific dietary adjustments and/or calorie deficit
  - Recurring receipts for a subscription to a lifestyle modification program (for example monthly)
    Examples: Noom, Weight Watchers, Vida, Lark, Signos, Wondr, Livongo, Omada, Newtopia, Virta, employer or plan-sponsored programs
  - Dietary log maintained by member detailing specific diet and/or calorie deficit
  - Recurring appointments for private nutritional counseling or medical nutrition therapy (receipt or chart documentation provided monthly)
- Physical Activity acceptable documentation (ONE required)
  - Provider chart notes specifying type, duration, and frequency of physical activity
Clinical and comorbidity information: List weight-related comorbidities and attach chart notes if applicable; indicate prediabetes, type 2 diabetes, and cardiovascular disease and attach supporting documentation when indicated.
If prediabetes is indicated, attach confirmation within past 6 months by A1c 5.7%-6.4% or FPG 100-125 mg/dL or OGTT 140-199 mg/dL, or select None and attach documentation as applicable.
Prior therapy and measurements: Provide prior medications tried and failed with dates (including prior weight-loss medications) and provide baseline and current height, weight, BMI with chart documentation.
Only one medication per form; incomplete forms may delay PA decisions.
Therapy specifics and certification: Indicate concomitant GLP-1 use, intolerance/contraindication to Zepbound if applicable, dosing (2.4 or 3 mg daily) and titration plans; provider certifies information is true.
Authorization does not guarantee payment.

Fax number and mailing address for submission

Fax to 1-866-240-8123 or mail to SPECARE/Pittsburgh address

The form lists examples of acceptable supporting documentation to demonstrate lifestyle modification efforts and relevant comorbidities, including specific examples for both diet and physical activity and instructions to attach chart notes or objective test results where applicable.

Provider Requirements & Submission Instructions

Prior Authorization

Submit separate PA for each medication

Provider must submit a separate prior authorization form for each requested medication and include required documentation. Fax the completed form and all clinical documentation to 1-866-240-8123 or mail per the form instructions.

Fax: 1-866-240-8123
Mail: per form instructions (see mailing address on form)

Documentation Required

Attach lifestyle modification documentation

Provider must attach at least one Diet documentation item and one Physical Activity documentation item from the acceptable lists and specify how many months the member has actively participated in a lifestyle modification program prior to initiating therapy.

Diet examples: provider chart notes detailing dietary adjustments/calorie deficit; recurring receipts for a subscription to a lifestyle program; member dietary log; recurring appointments for nutritional counseling (monthly)
Physical Activity examples: provider chart notes specifying type/duration/frequency; recurring gym membership receipts plus activity notes; wearable device summary reports (e.g., elevated HR >20 min ≥3x/week for a month); recurring personal trainer receipts and notes

Documentation Required

Attach objective lab or diagnostic documentation for prediabetes or cardiovascular disease when indicated

If prediabetes or cardiovascular disease is indicated, attach supporting documentation. For prediabetes, confirmatory test thresholds are: A1c 5.7%–6.4%, fasting plasma glucose (FPG) 100–125 mg/dL, or OGTT 140–199 mg/dL. If cardiovascular disease is indicated, attach chart notes or clinical documentation.

Documentation Required

Provide prior medication history

Provider must list prior medications the member has tried and failed with dates of therapy—including prior weight-loss medications such as Contrave, Wegovy, Qsymia, Xenical, Zepbound, prior Saxenda—and attach supporting records or chart notes.

Billing Rule

One medication per form

Only one medication may be requested per submitted form. Incomplete forms or multiple medications on one form may delay prior authorization decisions.

Fax the completed form and all clinical documentation to 1-866-240-8123 or mail per the form instructions to SPECARE/Pittsburgh. The prescribing physician must provide a signature and date; by signing the form the provider certifies that the information is true, accurate, and complete and acknowledges that authorization does not guarantee payment.

Background & Supporting Documentation Examples

This standardized PA request form is used to collect clinical and administrative information to support pharmacy benefit determinations for weight‑loss medications. It requests member, provider, and medication details; asks about participation in lifestyle modification programs; lists acceptable supporting documentation examples for diet and physical activity; requests documentation of weight‑related comorbidities and relevant laboratory or chart evidence; and requires the provider's certification and signature.

Acceptable documentation examples are grouped into two categories—Diet and Physical Activity—and the form requires at least one item from each category. Diet examples include provider chart notes detailing dietary adjustments or calorie deficit, recurring subscription receipts for lifestyle programs, a member‑maintained dietary log, or recurring receipts/notes for nutritional counseling. Physical activity examples include provider chart notes specifying type/duration/frequency, recurring gym membership receipts with activity notes, wearable device summary reports showing regular activity (for example, elevated heart rate >20 minutes ≥3×/week for a month), or recurring personal trainer receipts with notes.

OpenPayer

Medication Prior Authorization Form for weight-loss medications

Policy Form Overview

Documentation & Clinical Information Required for PA

Provider Requirements & Submission Instructions

Who & What This Form Applies To

Background & Supporting Documentation Examples

Revision History