Blue Shield of California · Obesity Class III (BMI 40 or higher) · Versión completa en inglés: /pa-letter/blue-shield-california--obesity-class-3/
Carta de PA para Blue Shield of California: Obesity Class III (BMI 40 or higher).
Plantilla defensible de carta para Zepbound (tirzepatide) or Wegovy (semaglutide 2.4 mg). BMI 40 or higher meets the most defensible threshold for anti-obesity pharmacotherapy under every major plan's PA criteria. No comorbidity is required at this BMI.
La carta misma está en inglés porque el revisor del plan la lee en inglés. La envuelve y la firma su clínico.
Cita de política: Blue Shield of California Medical Policy, Anti-Obesity Pharmacotherapy.
Nota del plan: Blue Shield CA has historically required BMI greater than or equal to 30, documented lifestyle intervention for at least six months and step therapy through phentermine where not contraindicated. Some Blue Shield Promise (Medi-Cal managed care) plans follow Medi-Cal PDL, which excludes GLP-1 for obesity indication entirely as of 2026.
Nota del plan: Blue Shield CA has historically required BMI greater than or equal to 30, documented lifestyle intervention for at least six months and step therapy through phentermine where not contraindicated. Some Blue Shield Promise (Medi-Cal managed care) plans follow Medi-Cal PDL, which excludes GLP-1 for obesity indication entirely as of 2026.
Lo que MedImpact realmente requiere
Blue Shield of California contrata la administración del beneficio de farmacia a MedImpact, que adjudica esta PA. Los criterios siguientes provienen de la política clínica del PBM publicada públicamente. Cumpla cada uno antes de enviar.
- Plan-affiliate dependent; criteria vary substantially across Blue Shield CA, Premera, Highmark and Medicaid MCO contracts
- Common baseline: BMI greater than or equal to 30 (or 27 with comorbidity), six-month lifestyle intervention
- Step therapy requirements vary, verify against your specific plan's criteria PDF, not generic MedImpact policy
- Reauthorization terms plan-dependent (most annual)
- Some Medi-Cal managed care plans under MedImpact exclude obesity-indication GLP-1 entirely (state PDL takes precedence)
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] Blue Shield of California Prior Authorization Department Submitted via: Blue Shield provider portal or fax 1-888-697-8122 Re: Prior Authorization Request, Zepbound (tirzepatide) or Wegovy (semaglutide 2.4 mg) 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 Blue Shield of California Prior Authorization Reviewer, I am the treating clinician for [Patient name]. I am writing to request prior authorization for Zepbound (tirzepatide) or Wegovy (semaglutide 2.4 mg) for treatment of Obesity Class III (BMI 40 or higher) (ICD-10: E66.01, E66.811, Z68.41, Z68.42, Z68.43, Z68.44, Z68.45). Clinical justification Obesity Class III (BMI greater than or equal to 40, ICD-10 E66.01) is the highest-severity category in the standard obesity classification and qualifies for FDA-labeled anti-obesity pharmacotherapy regardless of comorbidity status. The SURMOUNT-1 trial (Zepbound) enrolled adults with mean BMI 38, and a pre-specified subgroup with BMI greater than or equal to 35 achieved 25.0 percent mean weight loss at 72 weeks on the 15 mg dose. The STEP-1 trial (Wegovy) enrolled adults with mean BMI 37.9 and demonstrated 14.9 percent mean weight loss at 68 weeks. Class III obesity carries the highest comorbidity burden (T2D, OSA, hypertension, dyslipidemia, NAFLD, joint disease) and the highest mortality risk among obesity categories, supporting the strongest case for pharmacotherapy as part of a comprehensive treatment plan. 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 Blue Shield of California policy This request meets the criteria set out in Blue Shield of California Medical Policy, Anti-Obesity Pharmacotherapy: - Current weight, height, BMI (within the past 30 days) documenting BMI greater than or equal to 40 - ICD-10 Z68.4x code corresponding to BMI category (Z68.41 = 40-44.9, Z68.42 = 45-49.9, Z68.43 = 50-59.9, Z68.44 = 60-69.9, Z68.45 = 70+) - Six months of documented lifestyle intervention (dietitian visits, structured program participation, or prior anti-obesity medication trials) - Treatment plan: target weight loss, continued behavioral support, monitoring schedule - Consideration of bariatric surgery (documented discussion or contraindication strengthens the case) Supporting evidence The clinical case for Zepbound (tirzepatide) or Wegovy (semaglutide 2.4 mg) in this indication is supported by the following registration trials and outcomes data: - SURMOUNT-1 (Zepbound in adults with obesity), Jastreboff et al., NEJM 2022, DOI 10.1056/NEJMoa2206038 - STEP-1 (Wegovy in adults with obesity), Wilding et al., NEJM 2021, DOI 10.1056/NEJMoa2032183 - SURMOUNT-4 (Zepbound continuation versus withdrawal), Aronne et al., JAMA 2024 Plan-specific note Blue Shield CA has historically required BMI greater than or equal to 30, documented lifestyle intervention for at least six months and step therapy through phentermine where not contraindicated. Some Blue Shield Promise (Medi-Cal managed care) plans follow Medi-Cal PDL, which excludes GLP-1 for obesity indication entirely as of 2026. Requested action I am requesting prior authorization for Zepbound (tirzepatide) or Wegovy (semaglutide 2.4 mg) 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
Plantillas educativas únicamente. No constituyen asesoramiento legal ni médico. Las cartas deben ser firmadas por el clínico tratante (MD, DO, NP, PA) con autoridad de prescripción. Cada plan cambia los criterios trimestralmente. Verifique con el boletín de política de PA más reciente de su plan antes de enviar. No invente hallazgos clínicos. No altere la firma de un clínico.
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