CurrentHighmark Blueshield NenyPolicy N/A

Medication prior authorization form for Wegovy (semaglutide)

This document is a payer-specific prior authorization form used by providers to request coverage of Wegovy (semaglutide) and documents required clinical, dosing, and administrative information for members in the payer's service area.

Policy Summary

PayerHighmark Blueshield Neny

PolicyMedication prior authorization form for Wegovy (semaglutide)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a separate completed form (one per medication) with requested drug, strength, quantity, supply days, directions, diagnosis, and prescriber signature; fax to 1-866-240-8123 or mail to the address on the form.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

32numbered clinical questions on the form

4 pens / 28 daysstandard dosing supply

1-866-240-8123fax

Coverage Criteria and Required Clinical Inputs

Form-required clinical inputs for authorization

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Providers must supply documentation that supports the following items as applicable for evaluation:

Lifestyle modification: Member is using Wegovy in combination with a lifestyle modification program that encourages reduced calorie diet and increased physical activity, with documentation of duration in months.document months of participation

Attach one source from each category (Diet and Physical Activity).

Prior medication trials: Document prior weight-loss medications tried and failed with dates (examples listed: Contrave, Saxenda, Qsymia, Xenical, Zepbound, prior Wegovy).dates of therapy

Attach chart notes or receipts.

Dose and titration: Indicate whether Wegovy is being prescribed at 1.7 mg or 2.4 mg once weekly or will be titrated to those doses.dose = 1.7 or 2.4 mg weekly

If not at those doses, indicate plan.

Concurrent GLP-1 RA use: Confirm whether Wegovy will be used with another GLP-1 RA or GLP-1 RA combinations (for example, with insulin), and document therapeutic failure/intolerance to other GLP-1 RAs when diabetes with cardiovascular risk reduction is present.document prior GLP-1 RA failure/intolerance when applicable

Example: Ozempic.

Cardiovascular risk and PAD: Document if Wegovy is used for major adverse cardiovascular event risk reduction, pre-existing cardiovascular disease, or peripheral arterial disease, with specific supporting documentation if PAD is present (ABI <0.85, revascularization, or amputation).provide evidence

Attach relevant documentation.

Diabetes and prediabetes: Document diagnosis of type 2 diabetes or prediabetes and relevant confirmatory tests (A1c, FPG, OGTT) within specified ranges and timeframe when indicated.A1c 5.7-6.4% etc for prediabetes

Attach labs.

MASH/NASH specific: If used for MASH/NASH, documentation must include prescribing specialist (gastroenterologist or hepatologist), diagnostic testing (biopsy or NITs), fibrosis staging, risk factors, and evidence of standard of care pharmacologic treatment for comorbidities; exclude use with cirrhosis/decompensation/HCC as applicable.provide biopsy/NIT and F0-F4 staging

Attach chart notes and tests.

Statin and lipid therapy context: Document statin use/intolerance, trials of ezetimibe monotherapy, use as adjunct to maximally tolerated statin and ezetimibe, or adjunct to PCSK9 inhibitor when relevant to cardiovascular risk management.document intolerance or prior trials

Include CK/LFT/hospitalization info for statin intolerance.

Continuation of therapy: Indicate if member is currently on Wegovy and requires continued therapy; provide evidence of improvement/stabilization for certain indications (for example, NIT improvement in fibrosis).show improvement or stabilization when requested

Attach follow-up testing.

Use of Wegovy in members with evidence of cirrhosis, hepatic decompensation, or hepatocellular carcinoma (HCC) requires explicit documentation and is likely to be excluded for MASH/NASH-specific requests unless criteria are met. The form asks whether the member has evidence of cirrhosis, hepatic decompensation, or HCC and queries alcohol consumption thresholds (≤ 20 g/day for females and ≤ 30 g/day for males) as part of hepatologic assessment. For members with suspected or documented advanced liver disease, attach specialist documentation and diagnostic testing as requested on the form to support any exception to exclusion.

Standard Supply and Coding Notes

inv-03: Standard pen supply — 4 pens per 28 days (12 pens per 84 days)

Standard supply (28 days)4 pens per 28 days

Standard supply (84 days)12 pens per 84 days

Dosing schedule referencedWegovy dosing schedule specified as one pen per week

Form Submission, Documentation, and Action Requirements

Prior Authorization

Submission and form completion

One form must be submitted per requested medication. Required fields on the submission form include: drug name, drug strength/dose, requested quantity, and days of supply. For Wegovy, indicate whether the request is for the standard supply (4 pens per 28 days / 12 pens per 84 days) or exceeds that amount and provide rationale as requested below. Acceptable submission channels: electronic prior authorization portal, fax, or secure provider portal per payer instructions.

Submit one completed form per medication requested (do not combine multiple medications on a single form).
Required form fields: Drug name, Strength/dose, Requested quantity, Days supply (e.g., 28 days, 84 days), Directions, Diagnosis.
Submission channels: electronic PA portal, fax, or secure provider portal (follow payer-specific instructions).

Billing Rule

Exceeding standard supply

Requests that exceed the standard supply for Wegovy (greater than 4 pens per 28 days or greater than 12 pens per 84 days) require documentation that the standard supply was tried and found ineffective, intolerable, or would be clinically inappropriate. The provider must explain why the standard quantity would likely be ineffective or adversely affect drug effectiveness or member adherence.

Standard dosing: 4 pens per 28 days (12 pens per 84 days).
For >4 pens/28 days (or >12 pens/84 days), include documentation that the member failed or was intolerant to the standard supply OR clinical justification why the standard supply would be ineffective or harm adherence.
If the provider indicates the member needs >4 pens/28 days, answer the form’s follow-up questions: a) Has the member tried and failed the standard supply? b) Would the standard supply likely be ineffective or adversely affect effectiveness/compliance?

Documentation Required

Required supporting documentation

Attach supporting documentation that verifies participation in lifestyle modification and the clinical information provided on the form. For weight-management therapies, at least one documentation item from each category (Diet and Physical Activity) is required. Also attach relevant medical history, prior medication trials with dates, baseline and current vitals (height, weight, BMI), and any specialty testing or results when applicable (for example, MASH workup).

Lifestyle modification documentation — provide at least one item from each category:
Diet: provider chart notes documenting dietary changes or calorie deficit; dietary logs; recurring receipts for a paid lifestyle program; recurring appointments/receipts for nutritional counseling.
Physical activity: provider chart notes specifying type/duration/frequency; recurring gym membership receipts with activity notes; wearable device summary reports; recurring personal trainer receipts with notes.
Medical history and clinical data: chart notes for weight-related comorbidities; documentation of prior weight-loss medications with dates of therapy; baseline (pre-therapy) and current height, weight, and BMI with chart evidence.
Specialty documentation when applicable: for MASH/NASH — biopsy or noninvasive test results and fibrosis staging; for peripheral arterial disease — ABI or procedure/amputation documentation; for diabetes/prediabetes — lab results (A1c, FPG, OGTT) within required timeframes.

Step Therapy

Therapy trial requirements

Document trials of, intolerance to, or contraindications for alternative therapies as applicable. For step-therapy requirements, state prior medications tried, dates of therapy, and reason for discontinuation (inefficacy, intolerance, contraindication). When applicable, document therapeutic failure or contraindication to specific comparator agents (for example, prior GLP-1 RA for diabetes patients, or Zepbound intolerance when relevant).

List all prior weight-loss or comparator medications tried and failed with therapy dates (e.g., Contrave, Saxenda, Qsymia, Xenical, Zepbound, previous Wegovy); include reason for failure or intolerance.
If claiming intolerance/contraindication to a specific agent (e.g., Zepbound), provide chart documentation of the adverse event and rationale that it would not be expected with the requested therapy.
For diabetes with cardiovascular risk reduction claims, document failure/intolerance/contraindication to FDA‑approved GLP-1 RAs indicated for diabetes/CV risk reduction (for example, Ozempic) when required.

Background

Wegovy (semaglutide) is captured on the prior authorization form in the context of weight management and related clinical contexts including cardiovascular risk management, type 2 diabetes, prediabetes, and selected use in MASH/NASH. The form collects objective metabolic and cardiometabolic measures (for example, HbA1c ≥ 5.7%, 2‑hour post‑prandial glucose ≥ 140 mg/dL, triglycerides ≥ 150 mg/dL, and blood pressure ≥ 130/85 mmHg) and documents whether the member is receiving treatment for diabetes, lipid disorders, or hypertension to support medical necessity.

The form also records current Wegovy use, improvement or stabilization of fibrosis by noninvasive tests when relevant, and asks about concomitant standard-of-care pharmacologic treatments. Quantity and dosing are specified as 4 pens per 28 days (12 pens per 84 days), and the form requires justification and documentation if more than the standard supply is requested (including whether the member has tried and failed the standard supply and whether the standard supply would likely be ineffective or adversely affect effectiveness or compliance).

Key Definitions

inv-09: Definition of lifestyle modification program — accepted documentation examples

DefinitionLifestyle modification program: participation in a program that encourages reduced calorie diet and increased physical activity

Diet documentation (acceptable)Provider chart notes detailing dietary adjustments; recurring program receipts (e.g., Noom, monthly receipts); member dietary logs; recurring nutrition counseling appointment records

Physical activity documentation (acceptable)Provider chart notes specifying type/duration/frequency; recurring gym membership receipts with notes; wearable device summary reports showing activity; recurring personal trainer appointment receipts and notes

Initial Therapy Requirements

Initial therapy

Initial therapy evaluation requires lifestyle modification participation and documentation of prior weight-loss medication trials and baseline measures.

Initial therapy documentation: Document lifestyle modification participation, prior weight-loss medication trials with dates, baseline height/weight/BMI, and planned dosing (1.7 mg or 2.4 mg weekly titration).see form fields

Attach supporting documentation (diet and physical activity evidence, prior medication dates, baseline measurements).

Continuation Therapy Requirements

Continuation therapy

Continuation requests must indicate current Wegovy use and justification for continued therapy; provide evidence of benefit or stabilization where requested (for example, fibrosis improvement by NIT for MASH).

Current therapy: Member is currently on Wegovy and requires continued therapy; attach documentation.current use indicated

Question 20 and related items.

Step Therapy and Trial Documentation

Documented prior therapy (name)	Trial dates	Reason for discontinuation / intolerance
Zepbound	(provide dates of trial)	Therapeutic intolerance or contraindication (documented severe side effects not resolved by dose modification or documented allergic reaction/hypersensitivity)
GLP-1 RA approved for diabetes / CV risk reduction (e.g., Ozempic)	(provide dates of trial)	Therapeutic failure, intolerance, or contraindication to GLP-1 RA (when diabetes with CV risk reduction indication)
Ezetimibe monotherapy	(provide dates of trial)	Therapeutic failure, contraindication, or intolerance
Statins	(provide dates of trial(s) and specify at least two separate statins when claiming intolerance)	Intolerance (e.g., statin-related rhabdomyolysis or muscle symptoms resolving on discontinuation; CK or LFT elevations; hospitalization for severe adverse event)
Prior weight-loss medications (examples: Contrave, Saxenda, Qsymia, Xenical, prior Wegovy)	(provide dates of trial)	Therapeutic failure or intolerance (document dates and supporting chart notes/receipts)

Quantity Limits for Wegovy (semaglutide)

inv-13: Wegovy (semaglutide) — standard quantity: 4 pens per 28 days

DrugWegovy (semaglutide)

Standard quantity (28 days)4 pens per 28 days

Dosing schedule noteDosing schedule specified as one pen per week (pen per week)

inv-14: Wegovy (semaglutide) — alternative referenced quantity: 12 pens per 84 days

Alternative quantity (84 days)12 pens per 84 days

When to request moreIf member needs more than 4 pens per 28 days (12 pens per 84 days), provider must document trial and failure of standard supply and why standard supply would be ineffective or impair compliance

Form question linkageForm asks whether member needs >4 pens/28 days and requests documentation if yes (questions on trial and likely ineffectiveness)