Alberta Blue Cross copy of the industry initial medical statement for disability claims.
- Completed by
- Attending physician or other medical provider
- Issued by
- Alberta Blue Cross
- Format
- Fillable PDF
- Language
- English
Alberta Blue Cross Wegovy/Saxenda SA Form (ABC 60130)
Alberta Blue Cross employer plans use this one-page request when a prescriber seeks coverage of liraglutide (Saxenda), naltrexone-bupropion (Contrave), semaglutide (Wegovy) or tirzepatide (Zepbound) for weight loss. The prescriber picks one drug, marks the request as a first or second trial or a renewal, and documents pre-treatment BMI and weight, comorbidities, past interventions and response. Approval is not guaranteed.
Who completes it
The prescriber completes the patient, prescriber and drug sections, including their professional association registration (such as CPSA or CARNA) and a fax number, and signs; there is no patient signature.
Submitting and payment
- How to submit it
- Fax or mail it to Alberta Blue Cross Clinical Drug Services, and once a fax has transmitted successfully, do not mail or re-fax the same request.
Good to know
- A maximum of two trials per drug per lifetime is allowed, even if the patient did not respond or stopped before receiving enough therapy for a response.
- For adults with a BMI of 27 to under 30, list weight-related comorbidities such as hypertension, dyslipidemia, sleep apnea or type 2 diabetes, and the weight management interventions that failed.
- Renewals need the current body weight on the drug for adults, or the current BMI and response to therapy for pediatric patients.
- The form asks whether the drug will be used as an adjunct to a reduced-calorie diet and increased physical activity.
Get the official form
Download the current version from the source each time; forms change without notice.
Special Authorization Request Form – Liraglutide / Naltrexone + Bupropion / Semaglutide / Tirzepatide for Weight Loss
Fill it with Vero
Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
How this list is checked
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Frequently asked questions
Does Alberta Blue Cross cover Wegovy for weight loss?
Under Alberta Blue Cross employer plans, the prescriber requests it with this special authorization form, which notes that a request may or may not be approved. The form needs the patient's pre-treatment BMI and weight, comorbidities if the BMI is from 27 to under 30, and previous weight management interventions.
How many trials of a weight loss drug does ABC 60130 allow?
Two. The form allows a maximum of two trials per drug per lifetime, regardless of whether the patient failed to respond or stopped before receiving enough therapy for a response. Each request is marked as a new first trial, a new second trial or a renewal.
What prescriber details does ABC 60130 require?
The prescriber's name, address, phone and a fax number, which the form says must be provided with each request, plus the professional association registration (CPSA, CARNA, ACP, ACO, ADA+C or other) and registration number. The prescriber signs and dates the request before faxing or mailing it.