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UHCs typical prior authorization requirements for Wegovy and Zepbound include: BMI documentation A documented BMI of 30 or higher, or BMI of 27 or higher with at least one weight-related comorbidity such as type 2 diabetes, hypertension, dyslipidemia, or obstructive sleep apnea Comorbidity evidence Clinical records documenting the specific comorbidities that support the medical necessity of treatment Supervised weight management history Evidence of participation in a structured weight management program, which may include diet, exercise, and behavioral counseling, typically for 3 to 6 months prior to the request Prescriber qualifications The prescriber must be a physician, nurse practitioner, or physician assistant with appropriate prescribing authority UHC reviews prior authorizations against specific clinical policy bulletins
Mounjaro is currently under FDA review for MACE risk reduction
This approval fundamentally shifted how obesity was treated in mainstream medicine, moving from diet-and-exercise-only frameworks to pharmacotherapy-supported approaches
As another example, consider a new ACO inexperienced with performance-based risk Medicare ACO initiatives that enters the BASIC track's glide path at Level A for an agreement period beginning on January 1, 2026, based on the criteria used to determine ACO participation options specified at 425.600(g)
