[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-283877-105":53,"doc-detail-283877-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","zepbound-medication-prior-authorization-form","Zepbound Medication Prior Authorization Form","","Zepbound prior authorization form used to collect member, provider, and clinical details required for medication coverage decisions. Captures subscriber identifiers, prescriber information, requested drug name, strength, quantity, and day supply, plus diagnosis and treatment context. Includes clinical questions about concurrent lifestyle modification, duration of participation, weight-related comorbidities, prediabetes or type 2 diabetes status, prior weight-loss therapies, baseline and current measurements, additional medication use, and obstructive sleep apnea specifics with required test documentation.",{"@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/zepbound-medication-prior-authorization-form/283877/",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/zepbound-medication-prior-authorization-form/283877.png","ImageObject",442,249,{"name":88,"@type":89},"Mabel","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-29","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",13,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information is required from the member and provider on this form?","Question",{"text":109,"@type":110},"The form requires member identifiers (subscriber ID, group number, name, phone, birth date, and address) and provider details (physician name, NPI, contact info, address, signature, and date).","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What clinical documentation is requested for questions about lifestyle modification?",{"text":114,"@type":110},"It requests supporting documentation for answers to lifestyle modification questions, with acceptable evidence such as provider chart notes, diet or activity logs, recurring receipts for approved programs or gym memberships, and wearable-device summaries or trainer appointment records.",{"name":116,"@type":107,"acceptedAnswer":117},"What additional details are needed if the medication is being used for obstructive sleep apnea?",{"text":118,"@type":110},"It asks whether the prescribing is by or in consultation with a sleep specialist and requires baseline sleep apnea severity metrics (AHI, RDI, or REI) obtained from diagnostic testing without positive airway pressure or an oral appliance, along with supporting documentation.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},283877,1790459840,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":136,"language":137,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":138,"faqs":139,"seo_title":140,"seo_description":61,"update_tm":141,"read_time":73},7971474920318,"https://ap-avatar.wpscdn.com/avatar/74000ee537e6b0ca360?x-image-process=image/resize,m_fixed,w_180,h_180&k=1788430171632181674","Medication Prior Authorization Form Fax to 1-866-240-8123  \nZepbound  \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. Is the member using Zepbound in combination with a lifestyle modification program that encourages reduced calorie diet and increased physical activity (for example , 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 (for example , nutritional counseling, participation in a comprehensive weight management program) prior to initiating therapy with Zepbound:\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 (for example, 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 (for example, receipt or chart 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 (for example , 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 (for example , elevated heart rate for over 20 minutes for at least 3 times a week for a month)\u003Cbr>• Recurring appointments with a personal trainer (for example, 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 (for example, chart notes) to support this information.\u003Cbr>______________________________________________________________________________________\u003Cbr>______________________________________________________________________________________\u003Cbr>\u003Cbr>|\n| 4. Does the member have a diagnosis of prediabetes?\u003Cbr>☐ Yes ☐ No\u003Cbr>If YES:\u003Cbr>a. Was the member’s diagnosis of prediabetes confirmed by any of the following tests within the past 6 months?\u003Cbr>Please select ALL that apply:\u003Cbr>☐ An A1c of 5.7% to 6.4%\u003Cbr>☐ A fasting plasma glucose (FPG) of 100 mg/dL to 125 mg/dL\u003Cbr>☐ An oral glucose tolerance test (OGTT) of 140 to 199 mg/dL\u003Cbr>☐ None of the above\u003Cbr>If prediabetes was confirmed by any of these tests, please attach documentation (for example, chart notes) to support this information. |\n\n\n| 5. Does the member have a diagnosis of type 2 diabetes mellitus?\u003Cbr>☐ Yes ☐ No |\n| --- |\n| 6. Please provide any other medications that the member has tried and failed with dates of therapy, if applicable:\u003Cbr>Previous weight loss medications (for example, Contrave, Wegovy, Qsymia, Xenical, Saxenda, Foundayo,","cbCaibcCtEoAEtY3","https://ap.wps.com/l/cbCaibcCtEoAEtY3","pdf",275277,6,"English","# Member Information\n# Provider Information\n# Medication Information\n# Clinical Information\n## Lifestyle Modification Program\n## Weight-related Comorbidities\n## Prediabetes Testing (Past 6 Months)\n## Type 2 Diabetes Mellitus\n## Prior Medications Tried and Failed\n## Baseline Measurements\n## Current Weight Loss Medication Details\n## Combination With GLP-1 Therapy\n## Obstructive Sleep Apnea Treatment","[{\"question\":\"What information is required from the member and provider on this form?\",\"answer\":\"The form requires member identifiers (subscriber ID, group number, name, phone, birth date, and address) and provider details (physician name, NPI, contact info, address, signature, and date).\"},{\"question\":\"What clinical documentation is requested for questions about lifestyle modification?\",\"answer\":\"It requests supporting documentation for answers to lifestyle modification questions, with acceptable evidence such as provider chart notes, diet or activity logs, recurring receipts for approved programs or gym memberships, and wearable-device summaries or trainer appointment records.\"},{\"question\":\"What additional details are needed if the medication is being used for obstructive sleep apnea?\",\"answer\":\"It asks whether the prescribing is by or in consultation with a sleep specialist and requires baseline sleep apnea severity metrics (AHI, RDI, or REI) obtained from diagnostic testing without positive airway pressure or an oral appliance, along with supporting documentation.\"}]","Zepbound Medication Prior Authorization Form | PDF",1789621262]