Carta de PA para Blue Shield of California: Obesidad con una o más comorbilidades.

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, Wegovy (semaglutide 2.4 mg) or Zepbound (tirzepatide)
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 Wegovy (semaglutide 2.4 mg) or Zepbound (tirzepatide) for treatment of Obesity with one or more comorbidities (ICD-10: E66.01, E66.9, E66.811).

Clinical justification

Wegovy (semaglutide 2.4 mg) is indicated by FDA labeling for chronic weight management in adults with obesity (BMI greater than or equal to 30) or overweight (BMI greater than or equal to 27) with at least one weight-related comorbid condition. Zepbound (tirzepatide) carries the same labeling. The STEP-1 trial (Wegovy) demonstrated mean weight loss of 14.9 percent at 68 weeks. The SURMOUNT-1 trial (Zepbound) demonstrated mean weight loss of 22.5 percent at 72 weeks. Both trials enrolled the same patient population this PA is requesting.

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)
  - Comorbidity diagnosis with supporting ICD-10 (hypertension I10, dyslipidemia E78.x, T2D E11.x, OSA G47.33, NAFLD K76.0)
  - Six months of documented lifestyle intervention (dietitian visits, structured program participation, prior anti-obesity medication trials)
  - Failure or contraindication for plans that require step therapy through phentermine or orlistat
  - Treatment plan: target weight loss, continued behavioral support, monitoring schedule

Supporting evidence

The clinical case for Wegovy (semaglutide 2.4 mg) or Zepbound (tirzepatide) in this indication is supported by the following registration trials and outcomes data:

  - STEP-1 (Wegovy in adults with obesity)
  - STEP-3 (Wegovy with intensive behavioral therapy)
  - SURMOUNT-1 (Zepbound in adults with obesity)
  - SURMOUNT-4 (Zepbound continuation versus withdrawal)

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 Wegovy (semaglutide 2.4 mg) or Zepbound (tirzepatide) 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