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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.",{"@graph":63,"@context":119},[64,80,102],{"@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/weight-loss-agents-choice-prior-authorization-request-prescriber-fax/288877/",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/weight-loss-agents-choice-prior-authorization-request-prescriber-fax/288877.png","ImageObject",442,249,{"name":88,"@type":89},"Lucas Martin","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-07","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"Who is allowed to complete this prior authorization request form?","Question",{"text":109,"@type":110},"Only the prescriber may complete the form. 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For faster coverage determinations, [go to](go to www.CoverMyMeds.com)[ ](go to www.CoverMyMeds.com)[www.CoverMyMeds.com](go to www.CoverMyMeds.com).  \nOnly 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).  \nWhat is the priority level of this request?  Standard  \n Date of service (if applicable) :    \n 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.)  \nToday’s Date:    \nPATIENT INFORMATION  \nPatient Last Name:   Patient First Name:   Patient ID:   Date of Birth:   Patient Phone:   Patient Street Address:   City:   State:   Zip:    \nSex:  Male  Female Height:    in.  cm Weight:    lbs.  kg  \nAllergies:    \nPRESCRIBER INFORMATION  \nPrescriber Last Name:   Prescriber First Name:   Specialty:   Email:   Prescriber NPI:   DEA:   Prescriber Phone:   Prescriber Fax:   Prescriber Street Address:   City:   State:   Zip:    \nDRUG INFORMATION  \nDrug Name:   Drug Form:   Drug Strength:   Dosing Frequency:   Length of Therapy:   Quantity:    \nNumber of Refills:   Day Supply:    New Therapy  Renewal If renewal, date therapy initiated:   If renewal, duration of therapy (specific dates):   to    \nCRITERIA FOR ALL REQUESTS  \nNote: Please attach any additional information that should be considered with this request.  \nPatient’s Diagnosis:  \n Obesity  \n Other (ICD Code and Description below):  \nICD Code:   ICD Description:    \n1. What is the patient’s baseline weight and body mass index ( BMI ) prior to initiation of requested agent?  \nBaseline Weight:   kg Baseline BMI:   kg/m2  \n2. Is the requested agent being used for weight loss?  \n Yes  No  \n3. Is the patient currently treated with the requested agent?  \n Yes  No  \nIf Yes, when was therapy with the requested agent started?  \nIf Yes, has the patient demonstrated and maintained a weight loss from baseline?  Yes  No  \nIf Yes, please specify the following:  \nCurrent Weight:   kg Current BMI:   kg/m2  \nPercent weight loss from baseline:   %  \n4. Is the patient newly starting therapy with the requested agent?  \n Yes  No  \nIf No, please select one of the following:  \n The patient is attempting repeated weight loss course of therapy  \n The patient is continuing a current weight loss course of therapy  \n5. 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?  \n Yes  No  \n6. Is the patient attempting a repeated weight loss course of therapy?  \n Yes  No  \nIf Yes, is success anticipated with repeating therapy for the requested indication?  \n Yes  No  \n7. 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?  \n Yes  No  \nIf Yes, is the patient currently on and will continue a weight-loss regimen of a low-calorie diet, increased physical activity, and behavioral modifications?  \n Yes  No  \n8. Will the patient be using the requested agent in combination with another weight-loss agent (e.g. , Contrave, phentermine, Qsymia, Xenical, Saxenda, Wegovy, Zepbound)?  \n Yes  No  \n9. Is the patient’s age within FDA labeling for the requested indication for the requested agent?  \n Yes  No  \nIf No, is there information in support of using","cbCaiomfpWMsfFZg","https://ap.wps.com/l/cbCaiomfpWMsfFZg","pdf",1099659,6,"English","# Patient Information\n# Prescriber Information\n# Drug Information\n# Criteria for All Requests\n## Baseline weight and BMI\n## Prior and current use of requested agent\n## Prior targeted weight-loss agents\n## Lifestyle regimen before therapy\n## Combination therapy\n## Age labeling and contraindications\n# Criteria for Patients 12 to 17 Years of Age\n# Criteria for Patients Older Than 17 Years of Age","[{\"question\":\"Who is allowed to complete this prior authorization request form?\",\"answer\":\"Only the prescriber may complete the form. It is used for prospective, concurrent, and retrospective reviews.\"},{\"question\":\"What patient clinical data does the form collect?\",\"answer\":\"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.\"},{\"question\":\"What documentation is required for preauthorization consideration?\",\"answer\":\"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.\"}]","Weight-Loss Agents - Choice Prior Authorization Request - Prescriber Fax | PDF",1789634139]