Prior authorization form for GLP-1 agents (Wegovy, Zepbound) and related indications
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This document is a prior authorization request form used by prescribers to request coverage of specific GLP-1 receptor agonists (Wegovy, Zepbound) for indications including cardioprotection, NASH/MASH, and obstructive sleep apnea; it applies to Medicaid beneficiaries and providers submitting pharmacy PA requests in North Carolina. It outlines required clinical information and continuation criteria.
No material clinical or coverage changes in this revision.
Coverage Criteria and Indication-specific Requirements
Initial Therapy - Wegovy (cardioprotection)
Covered when ALL of the following are met:
All items correspond to checklist questions on the PA form
Initial Therapy - Wegovy (NASH/MASH)
Covered when ALL of the following are met:
Form requires listing FIB-4 score, supporting test(s), specialist involvement, and documentation of alcohol use and hepatic status
Initial Therapy - Zepbound (sleep apnea)
Covered when ALL of the following are met:
Form requests sleep hygiene counseling prior to initiation and attachment of sleep study documentation
Coverage is not appropriate for beneficiaries with decompensated cirrhosis or moderate to severe hepatic impairment (Child‑Pugh Class B or C) when Wegovy is requested for NASH/MASH. The form requires documentation that the beneficiary does not have decompensated cirrhosis and that Child‑Pugh Class B or C has been excluded prior to approval. In addition, therapy must not be provided when the product has any applicable FDA‑labeled contraindication (for example, personal or family history of medullary thyroid carcinoma or history of multiple endocrine neoplasia type 2) as indicated on the request form.
The request form asks the provider to confirm whether the beneficiary will be using the requested agent in combination with another GLP‑1 receptor agonist. Concomitant use with another GLP‑1 is queried as a checklist item and the policy does not support combination GLP‑1 therapy as standard practice; requests indicating concurrent GLP‑1 use are not consistent with the form’s ordering logic and would not be supported without clear clinical justification and documentation.
Initial therapy requirements
Covered when ALL of the following are met:
These are the indication-specific checklist items requested on the PA form and must be supported by submitted clinical documentation
Initial Therapy — Operational Criteria
STEP THERAPY / Medication Review Requirements
Before submitting an authorization request, confirm and document that required step-therapy and medication-review conditions are met. Failure to document prior lifestyle modification, or to confirm no concurrent GLP-1 use, may result in denial. If the patient is already using another GLP-1 receptor agonist, provide rationale and clinical justification for combination use — otherwise requests will be denied.
- Confirm ≥3 months of documented lifestyle modification (when required) and attach supporting records.
- Provide a current medication list and explicitly state whether the beneficiary is concurrently using any GLP-1 receptor agonist; concurrent use without justification will be a basis for denial.
- If requesting use contrary to step-therapy (e.g., initiating Wegovy/Zepbound without documented trials or lifestyle modification), include detailed clinical rationale and supporting medical records.
- Be aware: documentation-dependent denials and medication-review denials are operational risks — incomplete medication reconciliation or missing lifestyle documentation commonly leads to denial.
Continuation Therapy Requirements
Continuation Therapy
Covered when ALL of the following are met:
Continuation checklist mirrors initial criteria and requires submission of documentation of prior approval or clinical improvement
Continuation - Wegovy/Zepbound
Covered when ALL of the following are met:
Failure to provide required documentation (prior approval or evidence of improvement) may result in denial
Denial risk if supporting documentation not provided
Failure to include required supporting medical records and documentation that correspond to form answers may lead to denial of the request.
- Examples of documentation requested on the form: baseline weight/BMI, diagnostic test results (e.g., liver biopsy, VCTE, ELF, MRE), sleep apnea testing, and documentation of improvement for continuation requests.
- Form explicitly states: "Submit clinical documentation that supports the answers listed below for review."
Key Coding and Eligibility Thresholds
Provider Actions, Documentation & Operational Notes
Prior authorization required; verify prior Medicaid PA and improvement
Prior authorization is required for these agents. For continuation requests, confirm prior Medicaid PA approval (effective for covered indications since 10/01/2025) or provide initial evaluation if not previously approved; include documentation showing clinical improvement while on therapy.
- Form question: "Has the beneficiary been previously approved for the requested agent through Medicaid's Prior Authorization process for the covered indications that went into effect 10/01/2025?"
- Continuation requirement: "Has medical documentation that beneficiary has improved while on the medication been included with this request?"
Medication‑list review and potential dose reductions/discontinuations
Provider must confirm a review of the beneficiary's current medication list and document consideration of dose reductions or discontinuation of other medications for comorbid conditions as clinically appropriate while on the requested GLP‑1 agent.
- Form asks: "Has the provider performed a review of the beneficiary's medication list for possible dose reductions or discontinuation of medications for comorbid conditions...?" (Yes/No)
Required clinical documentation — attach supporting records for form answers
Attach clinical documentation that supports each affirmative answer on the form — e.g., baseline weight/BMI, diagnosis confirmation, FIB‑4 score and supporting liver testing (biopsy, VCTE, ELF, MRE) for NASH, sleep study results for Zepbound, and specialist consultation when indicated.
- Form header: "Submit clinical documentation that supports the answers listed below for review."
- Wegovy cardioprotection: baseline weight/BMI and diagnosis of established CVD must be documented on the form.
- Wegovy NASH/MASH: list FIB‑4 score and attach at least one supporting test (liver biopsy, VCTE, ELF, or MRE).
- Zepbound: attach documentation confirming sleep apnea testing and diagnosis.
GLP‑1 receptor agonists included on this form (Wegovy and Zepbound) are being requested across multiple distinct indications. Wegovy is requested for cardioprotection in adults with established cardiovascular disease and for treatment of noncirrhotic NASH/MASH with documented fibrosis staging; Zepbound is requested for patients with moderate to severe obstructive sleep apnea and obesity. For each indication the form requires baseline anthropometrics (weight and BMI), documentation of the qualifying diagnosis and supporting testing (for example, FIB‑4 and liver biopsy/VCTE/ELF/MRE for NASH; sleep study confirmation for OSA), screening for FDA‑labeled contraindications (including history of medullary thyroid carcinoma and MEN2), verification of age thresholds (Wegovy cardioprotection ≥ 45 years; NASH/MASH and Zepbound ≥ 18 years), and confirmation of ongoing lifestyle modification efforts prior to and during therapy.
Dispensing, Quantity and Duration Selections
Pharmacy form — provide quantity per 30 days and length of therapy
Specify Quantity Per 30 Days and select Length of Therapy (prescriber may choose up to 30, 60, 90, 120, or 180 days, or indicate another duration) on the Drug Information section of the form.
- Drug Information fields include: "Quantity Per 30 Days" and Length of Therapy options: up to 30, 60, 90, 120, 180 days, or Other.
Definitions and Diagnostic Criteria
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