Medication prior authorization form for weight-loss drugs (Qsymia)
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This document is a medication prior authorization (PA) form used by Highmark Pennsylvania to request coverage for Qsymia and other weight-loss medications; it governs what provider-submitted information and documentation are required for PA decisions for members in Highmark's service area.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial authorization criteria
Authorization support requires ALL of the following documented:
Provider must attach documentation from diet and physical activity categories; one item from each category is required.
Duration field on form must be completed and supported by attached documentation (e.g., recurring receipts, monthly program records, or chart notes).
Attach chart notes or other documentation showing baseline measures.
Attach documentation of prior medication history and dates when applicable to justify therapy selection.
The form does not list any additional explicit coverage criteria or exclusions beyond the initial authorization questions and documentation requests. The instructions emphasize procedural requirements (for example, submit a separate form for each medication) but do not add further clinical coverage conditions on the form itself.
The form does not present a separate list of conditions that are explicitly labeled not medically necessary. However, the form requires completion of specific fields and supporting documentation; incomplete or missing documentation (for example, failure to complete required form fields or to attach lifestyle program evidence) may result in denial or non-approval of the request.
Provider Submission & Documentation Requirements
Submission instructions
Fax the fully completed PA form and all supporting clinical documentation to 1-866-240-8123, or mail the form and attachments to the address on the form. Submit a separate authorization form for each medication requested.
- Fax number: 1-866-240-8123
- Mailing address: 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222
- Submit a separate form for each medication
Document prior medication trials with dates
Document prior use and therapeutic failure of other weight‑loss medications and include the specific dates of therapy to justify the requested treatment.
- Provide names of prior weight‑loss medications tried (examples listed on the form include Saxenda, Contrave, Wegovy, Xenical, Zepbound, previous Qsymia).
- Include dates of therapy for each prior medication.
Attach lifestyle modification documentation (diet and activity)
Attach evidence that the member has participated in a lifestyle modification program that includes both reduced‑calorie diet and increased physical activity. One item from the diet category and one item from the physical activity category are required.
- Acceptable diet evidence: provider chart notes detailing dietary adjustments, recurring program receipts/subscriptions, member dietary log, or recurring nutrition appointment documentation.
- Acceptable physical activity evidence: chart notes specifying type/duration/frequency, recurring gym receipts, wearable device activity summaries, or recurring trainer appointment receipts.
Provide baseline and current anthropometrics with chart notes
Attach chart documentation of the member's baseline height, weight, and BMI prior to initiating therapy; if the member is currently on a weight‑loss medication, also attach current height, weight, and BMI while on therapy.
- Baseline (prior to therapy) height, weight, and BMI must be provided and supported by chart notes.
- If member is currently on therapy, provide current height, weight, and BMI with supporting chart documentation.
Attach prior weight‑loss medication history with dates
Attach documentation listing prior weight‑loss medications that the member has tried and the dates of each therapy to support medical necessity.
- Form requests previous medications and dates of therapy (examples provided on the form).
- Include chart notes or records that verify the dates of prior therapies.
Omission of required lifestyle program evidence may cause denial
Failure to attach required evidence of participation in the lifestyle modification program (both diet and physical activity items) may result in denial or delay of the authorization.
- The form states: “Please attach documentation to support the answers to questions 1 and 2. One from each category is required.”
- Missing these diet and activity documents risks denial.
Complete all provider and medication form fields (signature, NPI, address)
Ensure all provider and medication fields on the form are complete, including physician name, NPI, address, signature, and date; incomplete or missing provider/medication information can cause processing delays or denial.
- Provider fields shown on the form include physician name, NPI, contact information, address, and physician signature/date.
- Instructions state to complete ALL information on the form; incomplete fields may lead to processing denial or delay.
Definitions
Background
This form is intended to support prior authorization requests for pharmacologic treatment of obesity (example queried on the form: Qsymia). It requires documentation that medication therapy will be used in combination with an active lifestyle modification program (reduced calorie diet plus increased physical activity), specifies the duration of prior participation in such a program (months), and directs the provider to attach supporting diet and activity documentation from the listed acceptable sources.
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