CurrentHighmark PennsylvaniaPolicy N/A

Medication prior authorization for Zepbound

This document is a medication prior authorization form used by Highmark Pennsylvania to request approval for Zepbound (weight management medication). It governs providers submitting authorization requests and members being considered for Zepbound therapy.

Policy Summary

PayerHighmark Pennsylvania

PolicyMedication prior authorization for Zepbound

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed form and all clinical documentation by fax to 1-866-240-8123 or by mail to Highmark SPECARE at 120 Fifth Avenue, Pittsburgh, PA 15222; one form per medication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Faxsubmission channel

Mailmail option

Diet, activity, sleeprequired docs

One per medform rule

Coverage Criteria for Zepbound Prior Authorization

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.

Initial authorization documentation requirements

Coverage requires submission of completed form with supporting clinical documentation demonstrating lifestyle modification efforts, relevant comorbidities, and baseline measurements.

Documentation and clinical verification: Provider must document (1) participation in a lifestyle modification program that encourages reduced calorie diet and increased physical activity and duration in months, with attached documentation from acceptable sources (diet documentation such as provider chart notes, dietary logs, recurring program receipts or nutrition counseling; and physical activity documentation such as chart notes, gym receipts, wearable device reports, or trainer receipts); (2) baseline height, weight, and body mass index (BMI) prior to initiating Zepbound with attached chart documentation; (3) prior weight-loss medication trials and dates if applicable; (4) if diagnosis of prediabetes is present, confirmatory test within the past 6 months (A1c 5.7%–6.4% or FPG 100–125 mg/dL or OGTT 140–199 mg/dL) with attached results; (5) for obstructive sleep apnea, baseline AHI and RDI from polysomnography or recording time without positive airway pressure or oral appliance and, if performed, baseline AHI/RDI after optimization of guideline-directed care, with attached sleep study reports; and (6) documentation of weight-related comorbidities as applicable.see documentation nodes

All supporting documentation types are listed on the form

Initial therapy requirements

Initial therapy requires demonstration of lifestyle modification efforts and baseline measures.

Initial therapy: Provide documentation of participation in a lifestyle modification program (reduced calorie diet and increased physical activity) with duration in months and attach supporting documentation (examples: provider chart notes, dietary logs, recurring program receipts, nutrition counseling records, wearable device reports); provide baseline height, weight, and BMI (before therapy with Zepbound or any other weight loss medication) with supporting chart documentation; list prior weight-loss medications tried and failed with dates if applicable.N/A

Acceptable documentation types are listed on the form

Continuation and Monitoring Requirements

Continuation/Monitoring

Continuation or ongoing therapy requires current on-therapy measures and documentation.

On-therapy monitoring: If member is currently on a weight loss medication, provide current (on-therapy) height, weight, and BMI and the duration on therapy; attach chart notes to support measurements and dates; for obstructive sleep apnea, provide current (after therapy) AHI and RDI with use of positive airway pressure or oral appliance as applicable and attach device reports or sleep study documentation; indicate whether continued Zepbound therapy is required to maintain improvement.N/A

Attach chart notes or device reports

Continuation for established therapy

For established use (including obstructive sleep apnea) where Zepbound has already been started, provide duration on therapy and current objective measurements to justify continuation.

Established therapy continuation: Specify how long the member has been on Zepbound and provide current AHI/RDI and positive airway pressure device reports or sleep study documentation if treating obstructive sleep apnea; indicate whether additional therapy with Zepbound is required to maintain a decrease in AHI/RDI; attach supporting documentation demonstrating benefit or need for continuation.N/A

Attach supporting documentation

Ongoing benefit or adherence: Provide evidence of clinical benefit or adherence while on therapy (for example, objective improvement in AHI/RDI, continued participation in lifestyle modification program, or documentation of weight change) and duration on therapy; attach chart notes or device reports as applicable.N/A

Documentation should be current and attached

Submission Instructions and Provider Requirements

Denial Risk

Submission and payment risk

Fax the completed form and all clinical documentation to 1-866-240-8123 or mail to: 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222. Submit a separate form for each medication. Print, type, or write legibly in blue or black ink. Complete ALL information on the form. The prescribing physician (PCP or Specialist) should, in most cases, complete the form. Provide the physician address for notification.

Submit a separate form for each medication
Fax: 1-866-240-8123
Mail: 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222
Complete ALL information on the form
Prescribing physician should complete the form
Provide physician address for notification

Documentation Required

Required supporting documentation

Attach documentation demonstrating the member's participation in a lifestyle modification program that includes both reduced calorie diet and increased physical activity. One item from each category (Diet and Physical Activity) is required.

Diet — provider chart notes detailing dietary adjustments and/or calorie deficit
Diet — recurring receipts for a lifestyle program subscription (for example, Noom, Weight Watchers, Vida, Lark, Signos, Wondr, Livongo, Omada, Newtopia, Virta, employer/plan-sponsored programs) provided monthly
Diet — dietary log maintained by member detailing diet/calorie deficit
Diet — recurring appointments for private nutritional counseling or medical nutrition therapy (receipt or chart documentation monthly)
Physical Activity — provider chart notes specifying type, duration, and frequency of activity
Physical Activity — recurring receipts for gym membership plus notes specifying type/duration/frequency
Physical Activity — summary report from a wearable device showing frequency (for example, elevated HR >20 minutes at least 3x/week for a month)
Physical Activity — recurring appointments with a personal trainer with notes specifying type/duration/frequency
Please attach chart notes to document weight-related comorbidities, prediabetes/type 2 diabetes, cardiovascular disease, and sleep study reports where applicable

Documentation Required

Previous therapy documentation

Provide prior therapy information for any previous weight-loss medications tried (examples: Contrave, Wegovy, Qsymia, Xenical, Saxenda, prior Zepbound), including dates of therapy and reason for discontinuation or failure. For members currently on a weight-loss medication, document the medication name, duration on therapy, and on-therapy height/weight/BMI. Include baseline (pre-therapy) height, weight, and BMI with supporting chart documentation.

List previous weight-loss medications with dates of therapy and outcomes/failure reasons
If currently on therapy: name of medication and duration on therapy
Provide baseline (before any current weight-loss medication) height, weight, and BMI with documentation
Provide current (on-therapy) height, weight, and BMI if member is presently on a weight-loss medication
Attach chart notes or other clinical documentation to support all dates, measures, and medication trials

Denial Risk

Submission and payment risk

Incomplete forms or missing supporting documentation may result in denial of the request. Payment is subject to member eligibility, benefit limits, and receipt of any required prior authorization. Ensure all requested documentation (clinical notes, lab tests, device reports, receipts, and program summaries) is included to avoid delays or adverse payment decisions.

Incomplete forms or missing documentation may lead to denial
Payment is subject to eligibility, benefit limits, and prior authorization requirements
Include clinical notes, lab reports (eg, A1c, FPG, OGTT where relevant), sleep study/device reports, and proof of program participation to support the request

Background

This prior authorization form supports requests for Zepbound, a GLP-1 receptor agonist indicated for weight management used in conjunction with lifestyle interventions. The form is designed to document the clinical rationale for therapy by capturing the member's participation in a structured lifestyle modification program (reduced calorie diet and increased physical activity), duration of participation, and objective baseline anthropometrics (height, weight, BMI) prior to initiating Zepbound.

The form also collects information about weight-related comorbidities (for example, prediabetes, type 2 diabetes, and atherosclerotic cardiovascular disease), prior weight-loss medication trials with dates, and, when applicable, detailed evaluation and management of obstructive sleep apnea including baseline and post-optimization AHI/RDI and documentation of positive airway pressure or oral appliance adherence. Submission instructions clarify that one completed form is required per medication and that the completed form and supporting clinical documentation must be faxed or mailed to Highmark for prior authorization review.

Previous weight‑loss medication	Dates of therapy (start — end)	Baseline height/weight/BMI documented
Contrave (naltrexone/bupropion)
Wegovy (semaglutide)
Qsymia (phentermine/topiramate)
Xenical (orlistat)
Saxenda (liraglutide)
Previous Zepbound
Other (specify)

OpenPayer

Medication prior authorization for Zepbound

Coverage Criteria for Zepbound Prior Authorization

Continuation and Monitoring Requirements

Step Therapy and Prior Medication Trials

Relevant Clinical Thresholds and Adherence Definitions

Submission Instructions and Provider Requirements

Key Definitions

Background