InScript

To submit a prior authorization online, please click the button below to use the web form.

WHEN SUBMITTING FOR GLP-1 FOR WEIGHT LOSS INDICATION:

IF YOU ARE A PHYSICIAN OR CLINIC, PLEASE DO NOT FILL OUT THIS FORM. PLEASE REFER PATIENT TO BILH WEIGHT LOSS MANAGEMENT CLINIC (SEE CONTACT INFORMATION BELOW).

For GLP-1 to be covered for weight loss, plan members are required to complete a Medication Therapy Management (MTM) virtual visit with the BILH Weight Loss Management Clinic prior to receiving a GLP-1 weight loss product. To assist with this process, please refer your patient to the BILH Weight Management Team to answer questions and schedule a visit at below:

BILH WEIGHT LOSS MANAGEMENT CLINIC
• Phone: 781-352-6551
• Fax: 339-227-4439
• E-mail: bilh-weightmanagementmtm@bilh.org

Exceptions to Clinic Requirement:
• Type 1 Diabetes
• Pediatrics (age 0-17 years)

PDF forms are available below to submit a prior authorization through fax.