Weight-Loss Agents - Choice Prior Authorization Request - Prescriber Fax

Sep 17, 2026

Weight-Loss Agents Choice Prior Authorization Request form for prescribers to submit prior authorization requests for prospective, concurrent, or retrospective coverage. Includes sections for patient demographics and clinical status, prescriber contact and identifiers, and detailed drug information. Captures whether the agent is used for weight loss, prior and current therapy history, baseline and current weight/BMI, prior targeted agent attempts, diet and behavioral measures, combination therapy, age labeling, contraindications, and supporting documentation requirements.

LanguageEnglish

CategoryForms

FormatPDF

Pages6

Reading Time2 min

AccessFree to download

Patient Information

Prescriber Information

Drug Information

Criteria for All Requests

Baseline weight and BMI

Prior and current use of requested agent

Prior targeted weight-loss agents

Lifestyle regimen before therapy

Combination therapy

Age labeling and contraindications

Criteria for Patients 12 to 17 Years of Age

Criteria for Patients Older Than 17 Years of Age

Weight-Loss Agents Choice Prior Authorization Request Prescriber Fax Fax this form to 800-424-3260 Prime Therapeutics Management LLC partners with CoverMyMeds to allow for the submission of electronic PA requests. For faster coverage determinations, [go to](go to www.CoverMyMeds.com)[ ](go to www.CoverMyMeds.com)[www.CoverMyMeds.com](go to www.CoverMyMeds.com). Only the prescriber may complete this form. This form is for prospective, concurrent, and retrospective reviews. Incomplete forms will be returned for additional information. The following documentation is required for preauthorization consideration. For formulary information visit [primetherapeutics.com/commercial-formularies](primetherapeutics.com/commercial-formularies). What is the priority level of this request? Standard Date of service (if applicable) : Urgent ( Note: Urgent is defined as when the prescriber believes that waiting for a standard review could seriously harm the patient’s life, health, or ability to regain maximum function.) Today’s Date: PATIENT INFORMATION Patient Last Name: Patient First Name: Patient ID: Date of Birth: Patient Phone: Patient Street Address: City: State: Zip: Sex: Male Female Height: in. cm Weight: lbs. kg Allergies: PRESCRIBER INFORMATION Prescriber Last Name: Prescriber First Name: Specialty: Email: Prescriber NPI: DEA: Prescriber Phone: Prescriber Fax: Prescriber Street Address: City: State: Zip: DRUG INFORMATION Drug Name: Drug Form: Drug Strength: Dosing Frequency: Length of Therapy: Quantity: Number of Refills: Day Supply: New Therapy Renewal If renewal, date therapy initiated: If renewal, duration of therapy (specific dates): to CRITERIA FOR ALL REQUESTS Note: Please attach any additional information that should be considered with this request. Patient’s Diagnosis: Obesity Other (ICD Code and Description below): ICD Code: ICD Description: 1. What is the patient’s baseline weight and body mass index ( BMI ) prior to initiation of requested agent? Baseline Weight: kg Baseline BMI: kg/m2 2. Is the requested agent being used for weight loss? Yes No 3. Is the patient currently treated with the requested agent? Yes No If Yes, when was therapy with the requested agent started? If Yes, has the patient demonstrated and maintained a weight loss from baseline? Yes No If Yes, please specify the following: Current Weight: kg Current BMI: kg/m2 Percent weight loss from baseline: % 4. Is the patient newly starting therapy with the requested agent? Yes No If No, please select one of the following: The patient is attempting repeated weight loss course of therapy The patient is continuing a current weight loss course of therapy 5. Has the patient tried a targeted weight-loss agent (e.g. , Adipex-P, phentermine, Benzphetamine, Contrave, Diethylpropion, Lomaira, Phendimetrazine, Qsymia, Saxenda, Wegovy, Xenical [orlistat]) in the past 12 months? Yes No 6. Is the patient attempting a repeated weight loss course of therapy? Yes No If Yes, is success anticipated with repeating therapy for the requested indication? Yes No 7. Has the patient been on a weight-loss regimen of a low-calorie diet, increased physical activity, and behavioral modifications for a minimum of 6 months prior to initiating therapy with the requested agent? Yes No If Yes, is the patient currently on and will continue a weight-loss regimen of a low-calorie diet, increased physical activity, and behavioral modifications? Yes No 8. Will the patient be using the requested agent in combination with another weight-loss agent (e.g. , Contrave, phentermine, Qsymia, Xenical, Saxenda, Wegovy, Zepbound)? Yes No 9. Is the patient’s age within FDA labeling for the requested indication for the requested agent? Yes No If No, is there information in support of using

FAQs

Who is allowed to complete this prior authorization request form?

Only the prescriber may complete the form. It is used for prospective, concurrent, and retrospective reviews.

What patient clinical data does the form collect?

It collects diagnosis details, baseline weight and BMI, whether the agent is used for weight loss, whether the patient is already on therapy and weight-loss maintenance, and current weight/BMI with percent weight loss when applicable.

What documentation is required for preauthorization consideration?

The form states that incomplete submissions will be returned for additional information and that supporting documentation should be attached for consideration. It also references formulary information for guidance.

Sep 17, 2026

Upload by Lucas Martin