CurrentHighmark Blueshield NenyPolicy N/A

Medication prior authorization form for Zepbound

Form and instructions for providers to request prior authorization for Zepbound (weight‑loss medication); collects member, provider, medication, and clinical documentation required to support coverage decisions.

Policy Summary

PayerHighmark Blueshield Neny

PolicyMedication prior authorization form for Zepbound

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form and all clinical documentation by fax to 1-866-240-8123 or by mail per instructions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12numbered clinical questions on form

30/90day supply options listed

multipleacceptable lifestyle evidences

faxsubmission method

Coverage and Assessment Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Core documentation and assessments: Member has documented participation in a lifestyle modification program (reduced calorie diet and increased physical activity) with attached supporting documentation; provider specifies duration of participation in months and attaches one acceptable item from each documentation category (diet and physical activity); provider provides baseline (pre‑therapy) height, weight, and BMI; provider lists prior weight‑loss medications and dates of therapy; provider documents presence or absence of weight‑related comorbidities including prediabetes, type 2 diabetes, and cardiovascular disease; provider answers whether member is using Zepbound with another GLP‑1 or GLP‑1 combination therapy.documented

Acceptable diet and activity evidence examples listed on form; one item required from each category

Prediabetes confirmation: If member has a diagnosis of prediabetes, confirm with one or more of the following tests performed within the prior 6 months: A1c 5.7%–6.4%, fasting plasma glucose 100–125 mg/dL, or oral glucose tolerance test (OGTT) 140–199 mg/dL; attach supporting documentation.within 6 months

Select all that apply

OSAHS-specific evaluation: If member has moderate to severe obstructive sleep apnea/hypopnea syndrome (OSAHS), attach baseline AHI obtained without positive airway pressure or oral appliance and baseline AHI after optimization with PAP/oral appliance; indicate whether medication was prescribed by or in consultation with a sleep specialist; provide documentation of PAP compliance (device report) when applicable and documentation of failure/intolerance to PAP or oral appliance; document at least six months of sleep hygiene measures and whether Zepbound is used concurrently; for members already established on Zepbound for OSAHS, provide duration on therapy and current (on‑therapy) AHI with device/oral appliance and state whether additional therapy with Zepbound is required to maintain AHI reduction.various

Multiple subquestions on form; attach sleep study or device reports as indicated

Clinical Measurements and Coding Inputs

Apnea/Hypopnea Index (AHI) — report numeric events/hour

AHI value to recordApnea/Hypopnea Index (AHI) — numeric events per hour to be provided on form (baseline and on‑therapy where applicable)

Source of AHIObtained from a baseline polysomnography or recording time (polysomnography or device report)

When to provideProvide baseline AHI WITHOUT use of positive airway pressure or oral appliance; if applicable provide AHI AFTER optimization with PAP/oral appliance and current on‑therapy AHI

Supporting documentationAttach baseline polysomnography, sleep study, or device report to support each AHI value provided

Submission and Documentation Requirements

Prior Authorization

Submission requirement

Submit the completed prior authorization form and all required clinical documentation. Fax the form and attachments to 1-866-240-8123 or mail to 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222. Submit one form per medication.

Fax: 1-866-240-8123
Mail: 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222
One form per medication

Documentation Required

Required supporting documentation

Attach evidence that the member has participated in a lifestyle modification program that includes both reduced-calorie diet and increased physical activity. Acceptable documentation must include at least one item from each category (diet and physical activity).

Diet documentation: provider chart notes, recurring program receipts (e.g., Noom, Weight Watchers, Omada), dietary logs, or recurring nutritional counseling receipts/chart notes
Physical activity documentation: provider chart notes or activity program records

Denial Risk

Incomplete submission / eligibility

Incomplete forms or missing supporting documentation may prevent authorization and can result in denial. Payment of any approved authorization is subject to member eligibility and plan benefits at time of service.

Complete ALL information on the form; the prescribing physician should, in most cases, complete the form
Include physician address for notification
Attach baseline and ongoing therapy documentation as applicable (e.g., height, weight, BMI, sleep study/device reports, device usage/compliance)

Drug and Program Background

Zepbound is addressed in this prior authorization form as a weight‑loss medication intended to be used in combination with lifestyle modification (reduced calorie diet and increased physical activity). The form collects baseline and on‑therapy height, weight, and BMI, comorbidities (for example, prediabetes, type 2 diabetes, cardiovascular disease), and other clinical details that support medical necessity when initiating or continuing Zepbound.

Key Definitions

Lifestyle modification program — examples and acceptable evidence

DefinitionLifestyle modification program — a program that encourages reduced calorie diet and increased physical activity (examples: nutritional counseling, comprehensive weight management programs)

Acceptable diet evidence (examples)Provider chart notes detailing dietary adjustments or calorie deficit; dietary logs maintained by member; recurring receipts for program subscriptions (Noom, Weight Watchers, Vida, Lark, Signos, Wondr, Livongo, Omada, Newtopia, Virta); recurring appointments/receipts for private nutritional counseling or medical nutrition therapy

Acceptable activity evidence (examples)Provider chart notes specifying type, duration, and frequency of physical activity; device reports or chart documentation of regular exercise sessions; recurring receipts for gym membership

Documentation requirementAttach one item from each category (diet and activity) to support participation and duration; specify months of participation on form

Apnea/hypopnea index (AHI) — definition

DefinitionApnea/hypopnea index (AHI) — events per hour obtained from polysomnography or device report used for baseline and on‑therapy assessment

Measurement sourcesBaseline AHI obtained from polysomnography or recording time; on‑therapy AHI may be from sleep study or positive airway pressure device report

Context on formForm requests baseline AHI WITHOUT PAP/oral appliance and baseline AHI AFTER optimization WITH PAP/oral appliance; current on‑therapy AHI requested for established Zepbound therapy

Criteria for Initiating Therapy

Initial therapy requirements

Initial therapy requires documentation of prior lifestyle modification and baseline measures and prior medication trials.

Initial therapy documentation: Document participation in a lifestyle modification program that includes reduced calorie diet and increased physical activity and specify duration in months; attach supporting diet evidence (one required) such as provider chart notes, recurring program receipts, dietary logs, or recurring nutrition counseling documentation; attach supporting physical activity evidence (one required) such as provider chart notes, recurring gym membership receipts, wearable device summary reports, or recurring personal trainer receipts.documented

One item required from each category of acceptable documentation as listed on the form

Baseline clinical measures: Provide baseline (BEFORE therapy) height, weight, and body mass index (BMI); attach chart notes or other documentation to support baseline measurements.baseline provided

Prior medication trials: List previous weight‑loss medications tried and dates of therapy (for example, Contrave, Wegovy, Qsymia, Xenical, Saxenda, prior Zepbound) and attach documentation of trials and outcomes as applicable.documented

Provider must document previous weight loss medications and dates of therapy

Criteria for Continuation / On‑Therapy

Continuation/On‑therapy information

For members currently on a weight‑loss medication, the form requests current therapy details and on‑therapy measurements to support continuation requests.

On‑therapy documentation: Specify which weight‑loss medication the member is currently taking and duration on therapy; provide current (while on therapy) height, weight, and BMI and attach chart notes to support these values.documented

Used to evaluate continuation needs

OSAHS on‑therapy assessment: For members with OSAHS established on Zepbound, provide duration on Zepbound, current (AFTER therapy) apnea/hypopnea index (AHI) with use of positive airway pressure or oral appliance and attach supporting sleep study or device report; indicate whether additional Zepbound therapy is required to maintain a decrease in AHI.documented

Prior medication	Dates of therapy (start - stop)
Contrave
Wegovy (semaglutide)
Qsymia
Xenical (orlistat)
Saxenda (liraglutide)
Prior Zepbound