Medication prior authorization form for Wegovy (coverage criteria)
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A payer-specific prior authorization form used by providers to request coverage for Wegovy (semaglutide) and collect required member, provider, medication, and clinical information to support medical necessity determinations. Applies to providers submitting authorization requests to Highmark in the covered service regions.
No material clinical or coverage changes in this revision.
Coverage Criteria for Wegovy (semaglutide)
Clinical information requested
Information requested to support medical necessity for Wegovy
Attach one form of documentation for diet and one for physical activity as listed on the form.
List dates of therapy for each prior medication trial.
Attach chart notes when applicable.
If MASH/NASH is selected, complete and attach documentation for questions 22–31 on the form.
Select hospitalization or other severe event as applicable and attach supporting documentation.
Continuation
Continuation therapy / current use queries
If member is currently on Wegovy, complete questions 29–31 and attach documentation demonstrating improvement/stabilization where applicable.
The prior authorization form specifically asks whether Wegovy is being used for major adverse cardiovascular event (MACE) risk reduction and whether it is being prescribed for Metabolic-Dysfunction Associated Steatohepatitis (MASH/NASH). For MACE, the form captures prior cardiovascular history (for example, prior stroke or myocardial infarction) and requests attached documentation when present. For MASH/NASH, the form requires confirmation that testing was performed (biopsy, noninvasive tests, ELF blood test, etc.), dates of testing, and fibrosis staging (F0–F4), and it requests documentation of relevant risk factors (BMI, waist circumference, fasting and 2‑hour glucose, HbA1c, lipids, blood pressure) and ongoing standard-of-care management. The form also queries whether Wegovy is being used concurrently with another GLP‑1 receptor agonist or with insulin, and asks providers to document prior GLP‑1 therapy failure/intolerance when applicable.
Completion and submission of the prior authorization form does not itself guarantee payment. The form instructions state that providers must submit a separate completed form for each medication and fax or mail the form with supporting clinical documentation, and they note that payment is subject to member eligibility and that authorization does not guarantee payment.
Clinical Thresholds and Coding-Adjacent Criteria
Submission and Documentation Requirements
One prior authorization form per medication; submit with clinical documentation
Submit a separate completed prior authorization form for each medication; include member, provider, medication, and clinical information. Fax the completed form and all clinical documentation to 1-866-240-8123 or mail to 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222.
Document prior weight‑loss medication trials and dates
List prior weight-loss medications the member has tried and failed and provide dates of therapy (examples listed on the form include Contrave, Saxenda, Qsymia, Xenical, Zepbound, and previous Wegovy). Attach documentation to support these prior treatment attempts.
- Provide dates of therapy for each prior medication listed on the form
Attach required supporting documentation (diet, activity, clinical data)
Attach documentation supporting lifestyle program participation and relevant clinical data; acceptable documentation includes chart notes, recurring receipts or logs, wearable device reports, prior medication trial records, baseline height/weight/BMI, and test/lab results (for example, MASH/NASH confirmation and fibrosis staging) as indicated on the form.
- Diet documentation: chart notes, recurring program receipts, or dietary logs
- Physical activity documentation: chart notes, gym receipts, wearable device summaries, or trainer receipts
- Clinical data: prior medication trials, baseline height/weight/BMI, biopsy or NITs/ELF for MASH with dates, fibrosis staging, and relevant labs
Authorization does not guarantee payment; verify member eligibility
Payment is subject to member eligibility; an authorization decision does not guarantee payment for the requested services.
Background and Purpose
This form collects the clinical details necessary to support medical necessity for initiating or continuing Wegovy (semaglutide). Required information includes documentation of participation in a lifestyle modification program (reduced calorie diet and increased physical activity) with duration and supporting evidence, baseline anthropometrics (height, weight, BMI), and a record of prior weight‑loss medications tried and dates. The form also requests condition‑specific evaluations where applicable (for example, MASH/NASH testing and fibrosis staging) and asks for documentation of therapeutic intolerance or contraindication to alternatives such as Zepbound when asserted.
Definitions and Program Examples
Initial Therapy Requirements
Initial therapy
Information required for initiating Wegovy
Acceptable documentation examples are specified on the form (chart notes, program receipts, dietary logs, wearable device reports, etc.).
Continuation Therapy Requirements
Continuation therapy
Questions for members currently on Wegovy
Complete questions 29–31 on the form when member is on therapy and attach supporting clinical data.
Prior Medication Trial Requirements
| Previous weight-loss medication | Dates of therapy |
|---|---|
| Contrave | (provider to list dates of therapy) |
| Saxenda | (provider to list dates of therapy) |
| Qsymia | (provider to list dates of therapy) |
| Xenical | (provider to list dates of therapy) |
| Zepbound | (provider to list dates of therapy; include documentation of intolerance if asserted) |
| Previous Wegovy therapy | (provider to list dates of prior Wegovy therapy) |
| Other (specify) | (provider to list medication name and dates of therapy) |
Quantity and Supply
Site of Care and Administrative Notes
No site-of-care restriction on the form
The form is an administrative submission and does not restrict site of care; providers may submit regardless of intended site of administration.
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