CurrentUnitedHealthcarePolicy N/A

NC Medicaid Pharmacy Prior Approval Request for Weight Management

This is a UnitedHealthcare North Carolina Medicaid prior authorization request form for weight management medications (specifically Wegovy, Saxenda, Zepbound and other GLP-1 agents). It collects beneficiary, prescriber, drug, clinical eligibility, prior therapy, contraindications, and continuity information to support PA decisioning and documents requirements for non-preferred drug justification.

Policy Summary

PayerUnitedHealthcare

PolicyNC Medicaid Pharmacy Prior Approval Request for Weight Management

Policy CodePolicy N/A

Change TypeForm / Administrative (no material coverage changes)

Effective Date

Next Review Date

Key ActionComplete and submit the NC Medicaid Pharmacy PA form with all beneficiary, prescriber, drug details, baseline and current weights/BMIs, dates, and prescriber signature.

POLICY UPDATE CHANGES

No material changes — brief indicates this is an administrative PA form with no listed policy changes.

3Agent examples referenced

3Response thresholds

1Prescriber signature required

Policy overview

This is a UnitedHealthcare North Carolina Medicaid prior authorization request form for weight management medications (specifically Wegovy, Saxenda, Zepbound and other GLP-1 agents). It collects beneficiary, prescriber, and drug information plus clinical eligibility details (age and BMI criteria, comorbidities, contraindications), prior therapy and non-preferred drug justification, and continuity/response information to support PA decisioning.

Coverage / Medical necessity criteria

Initial Request (Wegovy, Saxenda, Zepbound)

Covered when required form fields and listed clinical eligibility questions are completed to support PA decisioning:

ALL of the following

Baseline documentation: Provide beneficiary baseline weight and BMI with dates
Adults (>=18 years) BMI thresholds
- BMI >= 30 kg/m2: BMI greater than or equal to 30 kg/m2>= 30 kg/m2
- BMI >= 27 kg/m2 plus comorbidity: BMI greater than or equal to 27 kg/m2 AND at least one weight-related comorbidity/risk factor/complication (hypertension, type 2 diabetes, obstructive sleep apnea, cardiovascular disease, dyslipidemia)>= 27 kg/m2 + >=1 comorbidity
  Examples listed on form include hypertension, type 2 diabetes, obstructive sleep apnea, cardiovascular disease, dyslipidemia.
Adolescents (12-17 years)
- Adolescent BMI options
  - BMI >= 95th percentile for age and sex>= 95th percentile
  - BMI >= 30 kg/m2>= 30 kg/m2
  - BMI >= 85th percentile + comorbidity: BMI >= 85th percentile for age and sex AND at least one weight-related comorbidity/risk factor/complication (hypertension, type 2 diabetes, obstructive sleep apnea, cardiovascular disease, dyslipidemia)>= 85th percentile + >=1 comorbidity
Age-specific cardiovascular criteria for >=45
- If >=45 then BMI >=27 kg/m2: If >=45 years, BMI >= 27 kg/m2>= 27 kg/m2
- Established CVD required if BMI >=27: If BMI >=27 kg/m2, presence of established cardiovascular disease defined as history of myocardial infarction, stroke, or symptomatic peripheral disease
  Defined on form as history of myocardial infarction, stroke, or symptomatic peripheral disease.
Lifestyle modification: Document that beneficiary is currently on and will continue lifestyle modification including structured nutrition and physical activity unless physical activity is not clinically appropriate
No co-use of GLP-1s: Confirm beneficiary will NOT be using the requested agent with another GLP-1
Contraindications: Confirm no FDA-labeled contraindications to the requested agent (including pregnancy, lactation, history of medullary thyroid cancer or multiple endocrine neoplasia type II)

Continuation Request (Wegovy, Saxenda, Zepbound)

Continuation requests require documentation of prior approval and weight loss response:

Top-level continuation requirements

Prior approval confirmation: Confirm prior approval through NC Medicaid's PA process
Baseline and current weights/BMIs: Provide baseline and current weight and BMI with dates
Demonstration of treatment response
- Adult response >=5%: Adults (>=18 years): Has beneficiary lost a total of 5% of pretreatment weight and is maintaining the 5% weight loss?>= 5% total pretreatment weight loss maintained

Request for Non-Preferred Drug (Saxenda, Zepbound)

Provider must document one or more justifications to request a non-preferred agent:

Acceptable justifications for non-preferred drug

Failed preferred drugs: Failed preferred drug(s) — list preferred drugs failed and reason (allergy, drug-drug interaction)
Unacceptable side effect or therapeutic failure: Previous unacceptable side effect or therapeutic failure — provide clinical information
Clinical contraindication or unique circumstance: Clinical contraindication, comorbidity, or unique patient circumstance contraindicating preferred drugs — provide clinical information
Age-specific indications — provide patient age and explanation

Provider requirements & submission instructions

Prior Authorization

Prior authorization required

Submit the NC Medicaid Pharmacy PA form via the Pharmacy PA Call Center to request initial or continuation coverage for Wegovy, Saxenda, Zepbound, or non-preferred GLP-1 weight management agents.

Call Pharmacy PA Call Center: 1-855-258-1593
Use PA form sections for Initial Request or Continuation Request as appropriate

Documentation Required

Complete PA form with beneficiary/prescriber/drug details

Complete all beneficiary, prescriber, and drug information fields on the PA form. Include baseline and current weights and BMIs with dates, and ensure the prescriber signs the form (prescriber signature is mandatory).

Baseline weight and BMI with dates
Current weight and BMI with dates
Prescriber signature (mandatory)

Documentation Required

Clinical justification for non-preferred agents

When requesting a non-preferred GLP-1, document clinical justification on the form: list preferred drugs that failed and the reason(s), describe prior adverse reactions or therapeutic failures, note contraindications or comorbidities, provide age-specific indications or supporting literature, or explain unacceptable clinical risk.

List failed preferred agents and the reason(s) (e.g., allergy, drug–drug interaction, therapeutic failure, unacceptable side effects)

Documentation Required

Document lifestyle modification

Document that the beneficiary is currently on and will continue structured nutrition and physical activity (unless physical activity is not clinically appropriate) as part of the treatment plan.

Key thresholds and defined terms

Eligibility and response thresholds

Adult BMI threshold>= 30 kg/m2

Adult BMI with comorbidity>= 27 kg/m2 plus at least one weight-related comorbidity (e.g., hypertension, type 2 diabetes, obstructive sleep apnea, cardiovascular disease, dyslipidemia)

Adolescent BMI thresholds>= 95th percentile for age and sex; >= 85th percentile plus at least one weight-related comorbidity; or >= 30 kg/m2

Adult continuation response>= 5% total pretreatment weight loss maintained

Adolescent continuation response> 4% reduction in baseline BMI maintained

Weight-related comorbidity/risk factor/complication: Examples listed on the form include hypertension, type 2 diabetes, obstructive sleep apnea, cardiovascular disease, and dyslipidemia.

Established cardiovascular disease (CVD): Defined on the form as a history of myocardial infarction, stroke, or symptomatic peripheral disease.

Form purpose & scope

Form used to collect clinical and administrative information necessary to evaluate prior authorization requests for GLP-1 weight management agents under NC Medicaid. It captures age- and BMI-based eligibility (adult and adolescent thresholds, and age-specific cardiovascular criteria), documents comorbidities and FDA-labeled contraindications (including pregnancy, lactation, history of medullary thyroid cancer or MEN II), and records treatment response and continuation criteria (weight/BMI baseline and current values, percent weight/BMI reduction).

This UnitedHealthcare NC Medicaid prior authorization request form is specifically for weight management medications and lists agent examples including Wegovy, Saxenda, Zepbound.

OpenPayer

NC Medicaid Pharmacy Prior Approval Request for Weight Management

Policy overview

Coverage / Medical necessity criteria

Provider requirements & submission instructions

Key thresholds and defined terms

Coding

Form purpose & scope

Revision history