Carta de PA para Ambetter (Centene marketplace): Recuperación de peso post-bariátrica.

La carta (copiar y editar)

Copie el cuerpo a continuación y péguelo en el portal de su clínico o procesador de textos. Reemplace cada marcador de posición entre [CORCHETES] con datos específicos del paciente antes de enviar. La carta es de su clínico al plan, firmada por su clínico.

[Today's date]

Ambetter (Centene marketplace)
Prior Authorization Department
Submitted via: Ambetter provider portal, CoverMyMeds or fax 1-866-685-8664

Re: Prior Authorization Request, Wegovy or Zepbound
Patient: [Patient full name]
Member ID: [Plan member ID]
Date of birth: [Patient DOB]
Group number: [Group number if applicable]
Prescriber: [Prescriber full name, NPI, DEA]
Prescriber contact: [Phone, fax, email]

To the Ambetter (Centene marketplace) Prior Authorization Reviewer,

I am the treating clinician for [Patient name]. I am writing to request prior authorization for Wegovy or Zepbound for treatment of Post-bariatric weight regain (ICD-10: Z98.84, E66.01).

Clinical justification

Bariatric surgery is durable for most patients, but 20 to 50 percent experience clinically significant weight regain over the long term. Post-bariatric GLP-1 use has growing evidence: the 2024 BARI-OPTIMISE trial (Wegovy in patients with post-bariatric weight regain) demonstrated 8.8 percent mean weight loss versus 0.5 percent for placebo over 16 weeks. Post-bariatric status (ICD-10 Z98.84) does not exclude a patient from anti-obesity pharmacotherapy under any major plan's PA criteria; the qualifying criterion is current BMI plus comorbidities, regardless of how the patient reached that BMI.

Patient-specific findings

  - [Insert current measurements: weight, height, BMI, blood pressure]
  - [Insert relevant lab values with dates: A1c, lipid panel, kidney function]
  - [Insert documentation of comorbidities with ICD-10]
  - [Insert documentation of prior treatment history, including any prior GLP-1 trials, anti-obesity medication trials or lifestyle intervention]

Criteria met per Ambetter (Centene marketplace) policy

This request meets the criteria set out in Ambetter Clinical Policy CP.PMN.99, GLP-1 Receptor Agonists for Weight Management:

  - Current BMI and the date measured
  - Type and date of prior bariatric procedure (Roux-en-Y, sleeve gastrectomy, gastric bypass, duodenal switch)
  - Documented post-surgical weight nadir and current weight to establish regain pattern
  - Comorbidity status (T2D, hypertension, dyslipidemia, OSA) using ICD-10 codes
  - Bariatric surgeon or obesity medicine specialist co-signing the letter when possible

Supporting evidence

The clinical case for Wegovy or Zepbound in this indication is supported by the following registration trials and outcomes data:

  - BARI-OPTIMISE (semaglutide 2.4 mg in post-bariatric weight regain), Mok et al. 2024
  - Pajecki et al. 2023 (liraglutide in post-bariatric regain)

Plan-specific note

Ambetter is the ACA marketplace product from Centene-affiliated plans (operates in 25+ states under various local brands). Coverage of Wegovy and Zepbound for obesity requires BMI greater than or equal to 30 (or 27 with comorbidity), six months of documented lifestyle intervention and step therapy through phentermine or orlistat. Bronze and Silver tier plans frequently exclude anti-obesity medications from the formulary entirely; check your specific tier and state. Express Scripts is the PBM.

Requested action

I am requesting prior authorization for Wegovy or Zepbound at the [insert starting dose] starting dose, with planned titration per FDA labeling. I am also requesting that this authorization be granted for a continuous 12-month period subject to documented clinical response, per standard formulary practice.

If additional information is required, please contact me directly at [Prescriber phone] or [Prescriber email]. I am available to discuss this case with your medical director if helpful.

Thank you for your attention to this request.

Sincerely,

[Prescriber full signature]
[Prescriber printed name, credentials]
[Prescriber NPI]
[Practice name and address]

Attachments:
  - Current vital signs and BMI calculation
  - Most recent relevant labs
  - Documentation of comorbidities
  - Documentation of prior treatment trials
  - Sleep study report (if OSA indication)
  - Cardiac history documentation (if CV indication)

Aviso legal

John Samaras, Founder and editorI started GLP Chart after overpaying for a GLP-1 myself. Based in Austin, Texas. About this site · LinkedIn · Contact