Medication prior authorization for Zepbound
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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.
No material clinical or coverage changes in this revision.
Coverage Criteria for Zepbound Prior Authorization
Initial authorization documentation requirements
Coverage requires submission of completed form with supporting clinical documentation demonstrating lifestyle modification efforts, relevant comorbidities, and baseline measurements.
All supporting documentation types are listed on the form
Initial therapy requirements
Initial therapy requires demonstration of lifestyle modification efforts and baseline measures.
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.
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.
Attach supporting documentation
Documentation should be current and attached
Step Therapy and Prior Medication Trials
| 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) |
Relevant Clinical Thresholds and Adherence Definitions
Submission Instructions and Provider Requirements
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
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
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
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
Key Definitions
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.
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