Obesity-Management-Agents-PA-Form - Prior Authorization Form - Weight Management Agents

Sep 17, 2026

Upload by Rizky

Prior Authorization Form for Weight Management Agents collecting member and prescriber details, including demographics, contact information, provider identifiers, and practice address. It specifies TennCare generic requirements, criteria for preferred vs non-preferred weight management drugs, and lists medication classes such as appetite/absorption agents, GLP-1 weight management agents, neurobehavioral appetite modulators, and rare disorder obesity agents. The form also outlines clinical criteria, documentation requirements, and office-use fields with revision and page tracking.

LanguageEnglish

CategoryForms

FormatPDF

Pages5

Reading Time2 min

AccessFree to download

Instructions for Completing This Form

Member Information

Prescriber Information

Medication and Dispensing Information

Appetite and Absorption Agents (No PA Required)

GLP-1 Weight Management Agents

Neurobehavioral Appetite Modulators

Obesity Agents for Rare Disorders

Clinical Criteria

Prior Authorization Form Weight Management Agents INSTRUCTIONS FOR COMPLETING THIS FORM | Please fill out all sections on all pages completely and legibly. If the following information is not complete, correct, or legible, the prior authorization (PA) process can be delayed. Use one form per member, per drug, please. This form, along with other PA forms can be found at: [https://welcome.optumrx.com/tenncare/landing](https://welcome.optumrx.com/tenncare/landing).
MEMBER INFORMATION | | --- | | Member Last Name: Member First Name:
Member ID: Date of Birth (MM/DD/YYYY): Sex: ☐ Male ☐ Female
Street Address: City: State: ZIP:
Phone Number:
PRESCRIBER INFORMATION | | Prescriber Last Name: Prescriber First Name: Prescriber NPI: Prescriber DEA: Specialty: Office Phone: Office Fax: Supervising Physician and DEA (if applicable): Office Street Address: City: State: ZIP:
Is the prescriber a single patient contract holder for this patient? ☐ Yes ☐ No Is the prescriber a TennCare provider with a TN Medicaid ID? ☐ Yes ☐ No
Each of TennCare’s three Managed Care Organizations (MCOs) are offering wraparound services to support patients utilizing GLP-1 Agonists for weight management.
MEDICATION AND DISPENSING INFORMATION | Please refer to the Preferred Drug List or see below for Preferred and Non-Preferred Drugs in the Weight Management Agents classes. With the exception of the “Branded Drugs to be Classified as Generics List,” TennCare is a mandatory generic program in accordance with state law (TCA 53-10-205) . Approval of Non-Preferred agents requires trial and failure, contraindication, or intolerance of two (2) preferred agents, unless otherwise indicated on the PDL. Drug Name: Drug strength: Drug Formulation: Dosing Frequency: Quantity: Day Supply: Each of TennCare’s three Managed Care Organizations (MCOs) are offering wraparound services to support patients utilizing GLP-1 Agonists for weight management. The MCOs services include nutrition/dietician counseling, behavioral health support, case management/health coaching, and digital engagement. Please refer to the patient’s specific MCOto determine which services are available. BlueCare | UnitedHealthcare Community Plan | Wellpoint This document and others if attached contain information that is privileged, confidential, and/or may contain protected health information (PHI) . The Provider named above is required to safeguard PHI by applicable law. The information in this document is for the sole use of Optum Rx. Proper consent to disclose PHI between these parties has been obtained. If you received this document by mistake, please know that sharing, copying, distributing, or using information in this document is against the law. If you are not the intended recipient, please notify the sender immediately. Office use only: Weight Mgmt Agents PA Form 08/2026 Revision Date: 08/2026 Page 1 of 5 Member Last Name: DOB: Appetite and Absorption Agents (No PA Required*) *These agents are intended for short-term obesity management; and benefits should outweigh risks. Abrupt cessation should be avoided. Tapering is recommended. Please refer to the OTC Supplement Formulary for coverage of OTC products. | Preferred Drugs | Non-Preferred Drugs | | --- | --- | | benzphetamine tabs QL | N/A | | diethylpropion tabs QL | | | diethylpropion ER tabs QL | | | Lomaira® tabs QL | | | orlistat caps QL | | | phendimetrazine IR tabsQL | | | phendimetrazine ER caps QL | | | phentermine caps, tabs QL | | | phentermine/topiramate caps QL | | | Xenical® caps QL | | GLP-1 Weight Management Agents | Preferred Drugs | Non-Preferred Drugs | | --- | --- | | Wegovy® injection PA, QL | liraglutide (weight management) PA, QL | | Zepbound® single dose prefilled pen PA, QL | Saxenda® PA, QL | Neurobehavioral Appetite Modulators | Preferred Drugs | Non-Preferred Drugs | | --- | --- | | amphetamine sulfate tabs

FAQs

Who needs to complete this prior authorization form and how should it be submitted?

Fill out all sections on all pages completely and legibly. Use one form per member, per drug, and provide required medical records when requested to avoid delays.

What documentation is required for the clinical criteria section?

Medical records (for example, chart notes) confirming the diagnosis are required. Failure to provide requested documentation can delay the response.

How are preferred and non-preferred drugs handled under TennCare requirements?

With limited exceptions, TennCare follows a mandatory generic program. Approval of non-preferred agents generally requires trial and failure, contraindication, or intolerance of two preferred agents unless indicated otherwise on the Preferred Drug List (PDL).

Sep 17, 2026

Upload by Rizky