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Collects clinical information on lifestyle modification participation, weight-related comorbidities, prior medication trials with dates, and baseline metrics (height, weight, BMI), plus current metrics if already on weight loss therapy. Requires documentation supporting lifestyle and comorbidity answers and certification that information is true, accurate, and complete, with submission by fax or mail and notes on authorization payment eligibility.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/qsymia-medication-prior-authorization-form-fax-submission-instructions/287777/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/qsymia-medication-prior-authorization-form-fax-submission-instructions/287777.png","ImageObject",442,249,{"name":88,"@type":89},"Jasmine","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Where should the completed Qsymia prior authorization form and clinical documentation be sent?","Question",{"text":108,"@type":109},"Send the completed form and clinical documentation by fax to 1-866-240-8123 or mail to 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What information is required about the requested medication?",{"text":113,"@type":109},"Provide the drug name, drug strength, requested quantity, requested day supply selection (30 days, 90 days, or other), and directions, along with the diagnosis.",{"name":115,"@type":106,"acceptedAnswer":116},"What documentation must be attached for lifestyle modification questions 1 and 2?",{"text":117,"@type":109},"Attach documentation supporting the answers to questions 1 and 2. One item from the Diet category and one item from the Physical Activity category is required, such as provider chart notes, program receipts, dietary logs, or activity summaries.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},287777,1789632719,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":125,"read_time":9},2336478487870,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","Medication Prior Authorization Form Fax to 1-866-240-8123  \nQsymia  \nMember Information:  \n\n| Subscriber’s ID Number |  | Subscriber’s Group Number |\n| --- | --- | --- |\n| Member’s Name | Phone | Date of Birth |\n| Address City State Zip Code |  |  |\n\nProvider Information:  \n\n| Physician’s Name |  | NPI | Phone | Fax |\n| --- | --- | --- | --- | --- |\n| Address City State Zip Code |  |  |  |  |\n| Suite / Building | Physician’s Signature |  |  | Date |\n\nMedication Information:  \n\n| Drug Name | Drug Strength | Requested Quantity | Requested Day Supply ☐ 30 days\u003Cbr>☐ 90 days\u003Cbr>☐ Other:   |\n| --- | --- | --- | --- |\n| Directions |  |  |  |\n| Diagnosis |  |  |  |\n\nClinical Information:  \n\n| 1. Will the member use Qsymia in combination with a lifestyle modification program that encourages reduced calorie diet and increased physical activity (e.g. , nutritional counseling, participation in a comprehensive weight management program)?\u003Cbr>☐ Yes ☐ No\u003Cbr>2. Please specify how long (in months) this member has actively participated in a lifestyle modification program that encourages both a reduced calorie diet and increased physical activity (e.g. , nutritional counseling, participation in a comprehensive weight management program) prior to initiating therapy with Qsymia:\u003Cbr>  months\u003Cbr>* Please attach documentation to support the answers to questions 1 and 2.\u003Cbr>Acceptable forms of documentation are listed below.\u003Cbr>One from each category is required.\u003Cbr>Diet\u003Cbr>• Provider chart notes detailing specific dietary adjustments and/or calorie deficit\u003Cbr>• Recurring receipts for a subscription to a lifestyle modification program, such as Noom, Weight Watchers, Vida, Lark, Signos, Wondr, Livongo, Omada, Newtopia, Virta, plan sponsored coaching programs such as My Weight Management Journey or Penn State Health obesity medicine institute (e.g. , monthly, provided for each month)\u003Cbr>• Dietary log maintained by member detailing specific diet and/or calorie deficit\u003Cbr>• Recurring appointments for private nutritional counseling or medical nutrition therapy (e.g. , receipt orchart documentation provided monthly)\u003Cbr>Physical Activity\u003Cbr>• Provider chart notes specifying type, duration, and frequency of physical activity\u003Cbr>• Recurring receipts for a gym membership (e.g. , monthly, provided for each month) and notes specifying type, duration, and frequency of physical activity\u003Cbr>• Summary report from a wearable device specifying frequency of physical activity (e.g. , elevated heart rate for over 20 minutes for at least 3 times a week for a month)\u003Cbr>• Recurring appointments with a personal trainer (e.g. , receipt provided monthly) and notes specifying type, duration, and frequency of physical activity) |\n| --- |\n| 3. Please list any weight-related comorbidities this member has, if applicable:\u003Cbr>*Please attach documentation (e.g., chart notes) to support this information.\u003Cbr>______________________________________________________________________________________\u003Cbr>______________________________________________________________________________________ |\n| 4. Please provide any other medications that the member has tried and failed with dates of therapy, if applicable:\u003Cbr>Previous weight loss medications (e.g. Saxenda, Contrave, Wegovy, Xenical, Zepbound, previous Qsymia therapy, etc) Dates of therapy |\n\n\n| 5. Please provide the member’s baseline (prior to therapy with Qsymia or any other current weight loss medication):\u003Cbr>Height:   Weight:   Body Mass Index:  * Please attach documentation (e.g., chart notes) to support above information. |\n| --- |\n| 6. Only fill out this section for members currently on a weight loss medication.\u003Cbr>• Which weight loss medication is the member currently taking?  \u003Cbr>• How long has the member been on this medication? \u003Cbr>• Please provide the member’s current (while on therapy with Qsymia or other weight loss medication):\u003Cbr>Height:   Weight:   Body Mass Index:  * Please attach documentation (e.g., chart notes) to support abov","cbCaivYodWUf3zPE","https://ap.wps.com/l/cbCaivYodWUf3zPE","pdf",126702,"English","# Member Information\n# Provider Information\n# Medication Information\n# Clinical Information\n## Lifestyle Modification Questions 1-2\n## Comorbidities Question 3\n## Prior Medications Question 4\n## Baseline Metrics Question 5\n## Current Treatment Metrics Question 6\n# Submission Instructions","[{\"question\":\"Where should the completed Qsymia prior authorization form and clinical documentation be sent?\",\"answer\":\"Send the completed form and clinical documentation by fax to 1-866-240-8123 or mail to 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222.\"},{\"question\":\"What information is required about the requested medication?\",\"answer\":\"Provide the drug name, drug strength, requested quantity, requested day supply selection (30 days, 90 days, or other), and directions, along with the diagnosis.\"},{\"question\":\"What documentation must be attached for lifestyle modification questions 1 and 2?\",\"answer\":\"Attach documentation supporting the answers to questions 1 and 2. One item from the Diet category and one item from the Physical Activity category is required, such as provider chart notes, program receipts, dietary logs, or activity summaries.\"}]","Qsymia Medication Prior Authorization Form - Fax Submission Instructions | PDF"]