Prior authorization forms for weight-loss and GLP-1 medicines

For chronic weight management with diet and activity; asks for pre-treatment BMI and weight; adults with BMI 27 to under 30 need a weight-related comorbidity and a failed prior weight management intervention. Maximum of two trials per drug per lifetime. Renewal asks for current weight (adults) or BMI and response (pediatric).

Summarized from the form itself; the form and the plan contract decide, not this summary.

Weight: adults BMI 30 or more, or 27 to 29 with a comorbidity (dyslipidemia, hypertension, sleep apnea, type 2 diabetes, prediabetes, CVD); adolescents 12 to 17 at or above the 95th percentile; at least one failed diet or exercise attempt of 3 to 6 months; no other GLP-1; max 2.4 mg weekly. Separate sections for MASH (F2 to F3, specialist confirmed) and MI prevention (established CVD). Canada Life may require purchase from a designated pharmacy.

Summarized from the form itself; the form and the plan contract decide, not this summary.

Adults BMI 30 or more, or 27 to 29 with a comorbidity (including sleep apnea and CVD), with diet and activity, not with another GLP-1; adolescents at or above the 95th percentile. Physician fees are not covered by the PSHCP.

Summarized from the form itself; the form and the plan contract decide, not this summary.

Form asks for BMI, height, weight, obesity-related risk factors (hypertension, diabetes, hyperlipidemia, cardiac disease) and confirms lifestyle therapy is prescribed and continuing. ClaimSecure guidelines (Aug 2025): BMI 30 or more, or 27 to 29 with a comorbidity; renewal yearly with at least 5% weight loss kept; lifetime maximum per the plan anti-obesity coverage.

Summarized from the form itself; the form and the plan contract decide, not this summary.

No BMI cut-offs printed; the physician reports weight, height, BMI, documented comorbidities (CVD, dyslipidemia, hypertension, sleep apnea, T2DM, MASH), prior treatments, and confirms a low-calorie diet and increased activity plan is under way. Renewal asks for start and current weight and BMI. A new request is needed when the authorized period ends.

Summarized from the form itself; the form and the plan contract decide, not this summary.

Age 12 and up (Contrave and Zepbound adults only); no combination therapy. Measurements within 60 days; at least 150 minutes a week of vigorous exercise for 6 months (or low-impact activity), dietitian training, two or more reduced-calorie diets tried, bariatric surgery history. Initial approval 6 months; renewal only if 5% or more weight lost and kept off (4% BMI for adolescents). No BMI cut-off printed.

Summarized from the form itself; the form and the plan contract decide, not this summary.

Adults: BMI 30 or more, or 27 or more with a weight-related comorbidity, with diet and activity; renewal needs 5% or more weight loss. Adolescents 12 to 18: 95th percentile, over 60 kg, failed diet and activity; renewal 5% weight or 4% BMI loss. Also non-fatal MI risk reduction (established CVD, BMI 27 or more). Eligibility depends on plan design.

Summarized from the form itself; the form and the plan contract decide, not this summary.

Age 12 and up (Contrave and Zepbound adults only); no combination therapy. Measurements within 60 days; at least 150 minutes a week of vigorous exercise for 6 months (or low-impact activity), dietitian training, two or more reduced-calorie diets tried, bariatric surgery history. Initial approval 6 months; renewal only if 5% or more weight lost and kept off (4% BMI for adolescents). No BMI cut-off printed.

Summarized from the form itself; the form and the plan contract decide, not this summary.

Age 12 and up (Contrave and Zepbound adults only); no combination therapy. Measurements within 60 days; at least 150 minutes a week of vigorous exercise for 6 months (or low-impact activity), dietitian training, two or more reduced-calorie diets tried, bariatric surgery history. Initial approval 6 months; renewal only if 5% or more weight lost and kept off (4% BMI for adolescents). No BMI cut-off printed.

Summarized from the form itself; the form and the plan contract decide, not this summary.

Age 12 and up (Contrave and Zepbound adults only); no combination therapy. Measurements within 60 days; at least 150 minutes a week of vigorous exercise for 6 months (or low-impact activity), dietitian training, two or more reduced-calorie diets tried, bariatric surgery history. Initial approval 6 months; renewal only if 5% or more weight lost and kept off (4% BMI for adolescents). No BMI cut-off printed.

Summarized from the form itself; the form and the plan contract decide, not this summary.

No BMI cut-off printed: asks for height, weight, BMI, waist, comorbidities, goals, action plan, weight program, diet and activity strategies and their results, and prior therapies. Renewals only for patients who lose at least 5% and keep it off; initial and current measurements required.

Summarized from the form itself; the form and the plan contract decide, not this summary.

Adults: BMI 30 or more, or 27 or more with a weight-related comorbidity, used with diet and activity, dose at or below 2.4 mg weekly; renewal needs 5% or more weight loss achieved and maintained from baseline. Pediatric: BMI at or above the 95th percentile, weight over 60 kg, failed diet and activity alone. Also a non-fatal MI risk reduction section (BMI 27 or more, established CVD, HbA1c under 6.5%). Manulife may recommend a preferred pharmacy.

Summarized from the form itself; the form and the plan contract decide, not this summary.

Medavie website criteria (adiposity-based chronic disease): waist 102 cm men or 88 cm women with BMI 27 to 34.9, or BMI 35 or more (lower cut-offs for some Asian ethnicities). Form asks for pre-treatment weight, BMI and waist, at least 6 months of diet, activity and behavioural intervention in the past 24 months, and adiposity-related complications with test results. Renewal: pre and current measures and at least 12 weeks at maintenance dose.

Summarized from the form itself; the form and the plan contract decide, not this summary.

Adults BMI 30 or more, or 27 or more with a weight-related comorbidity (such as OSA), with diet and activity; also MI risk reduction (established CVD, BMI 27 or more), MASH, and adolescents (95th percentile, over 60 kg, failed diet and activity). Asks for proof of prior weight-loss attempts; renewal asks for initial BMI and clinical response.

Summarized from the form itself; the form and the plan contract decide, not this summary.

Adults 18 and up; at least 6 months of reduced-calorie diet and increased activity without reaching target; BMI 40 or more, or 35 or more with hypertension, dyslipidemia or sleep apnea; no previous Ozempic reimbursement by PBC or PharmaCare. Initial 6 months; renewal (1 year) needs at least 5% weight loss maintained.

Summarized from the form itself; the form and the plan contract decide, not this summary.

Age 12 and up (Contrave and Zepbound adults only); no combination therapy. Measurements within 60 days; at least 150 minutes a week of vigorous exercise for 6 months (or low-impact activity), dietitian training, two or more reduced-calorie diets tried, bariatric surgery history. Initial approval 6 months; renewal only if 5% or more weight lost and kept off (4% BMI for adolescents). No BMI cut-off printed.

Summarized from the form itself; the form and the plan contract decide, not this summary.

No BMI cut-off printed: asks for diagnosis, BMI, weight, comorbidities (arthritis, dyslipidemia, heart disease, hypertension, sleep apnea, T2DM), and whether the patient is on a reduced-calorie diet and increased activity.

Summarized from the form itself; the form and the plan contract decide, not this summary.

Adults: BMI 30 or more, or 27 or more with a weight-related comorbidity, with diet and activity; renewal needs 5% or more weight loss. Adolescents 12 to 18: 95th percentile, over 60 kg, failed diet and activity; renewal 5% weight or 4% BMI loss.

Summarized from the form itself; the form and the plan contract decide, not this summary.