Wegovy Prior Authorization Resources
Find the right PA form for your patient's payer, get the ICD-10 codes you need, and download appeal templates — all in one place.
Blue Cross Blue Shield of Arkansas - Pharmacy Prior Authorization Form Arkansas Blue Cross Blue Shield
Blue Cross of Idaho - General Prior Authorization Form Blue Cross of Idaho Health Services, Inc.
California - Uniform Prior Authorization FormCalifornia
CDPHP - General Prior Authorization FormCapital District Physicians Health Plan, Inc.
Cigna - General Medication Prior Authorization FormCigna Corporation
Colorado - Uniform Prior Authorization FormColorado
ICD-10 codes for Wegovy Prior Authorizations
E66.9Obesity, unspecifiedE66.01Morbid (severe) obesity due to excess caloriesE66.09Other obesity due to excess caloriesE66.811Obesity, class 1E66.812Obesity, class 2E66.813Obesity, class 3E66.3OverweightE66Overweight and obesityK75.81Nonalcoholic steatohepatitis (NASH)
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Appeal Templates
If the payer denies coverage, these templates help you build a stronger appeal.A peer-to-peer review with the payer's medical director can often resolve denials faster than a formal appeal.
Sample Appeal Letter for Coverage DenialTemplate for appealing coverage denials. Includes clinical justification framework and payer-specific language. Streamlines the appeal process for HCPs.
Sample Appeal Letter for Coverage Denial (wegovy-sample-l)Template for appealing coverage denials. Includes clinical justification framework and payer-specific language. Streamlines the appeal process for HCPs.
Letter of Medical Necessity TemplatePre-written LON template for PA requests. Includes medical justification, ICD-10 codes, and clinical criteria. Supports faster approval.
Letter of Medical Necessity Template (letter-of-medic)Pre-written LON template for PA requests. Includes medical justification, ICD-10 codes, and clinical criteria. Supports faster approval.
Sample Appeal Letter for Coverage Denial (sample-letter-o)Template for appealing coverage denials. Includes clinical justification framework and payer-specific language. Streamlines the appeal process for HCPs.
Brand Resources
Prior Authorization Guide for WegovyComprehensive PA guide with criteria, forms, and submission process. Helps HCPs navigate insurance requirements efficiently.
Prior Auth Letter to Employer TemplateLetter template requesting employer to add Wegovy to formulary. Includes cost-effectiveness data and clinical benefits.
Prior Authorization Quick Reference GuideQuick PA guide with common criteria, required documentation, and submission tips. One-page reference for busy HCPs.
Prior Authorization Guide for Wegovy (prior-authoriza)Comprehensive PA guide with criteria, forms, and submission process. Helps HCPs navigate insurance requirements efficiently.