missouri medicaid glp 1 prior authorization form

missouri medicaid glp 1 prior authorization form GL5197E (Wegovy), Manulife Group Benefits Drug (Wegovy/Semaglutide) – GL5197E - MLI (08/2025-WEGOV) missouri medicaid glp 1 prior

Name: missouri medicaid glp 1 prior authorization form GL5197E (Wegovy), Manulife Group Benefits Drug (Wegovy/Semaglutide) – GL5197E - MLI (08/2025-WEGOV) missouri medicaid glp 1 prior
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SKU: 60026609067
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Are there specific clinical criteria required for approval (e.g., BMI thresholds, sustained weight requirements, step therapy such as participation in a weight management program)