Blue Shield of California · Diabetes tipo 2 · Versión completa en inglés: /pa-letter/blue-shield-california--t2d/
Carta de PA para Blue Shield of California: Diabetes tipo 2.
Plantilla defensible de carta para Ozempic (semaglutide) or Mounjaro (tirzepatide). T2D is the most defensible PA path. ADA Standards of Care list GLP-1 RA as a preferred second-line agent with documented cardiovascular and renal benefit.
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, Ozempic (semaglutide) or Mounjaro (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 Ozempic (semaglutide) or Mounjaro (tirzepatide) for treatment of Type 2 diabetes (ICD-10: E11.9, E11.65). Clinical justification Per the American Diabetes Association 2026 Standards of Medical Care in Diabetes, GLP-1 receptor agonists are recommended as a preferred second-line therapy for patients with T2D and established atherosclerotic cardiovascular disease, heart failure or chronic kidney disease, independent of A1c. For patients without these comorbidities, GLP-1 RA is recommended when glycemic control is inadequate on metformin and the patient has a compelling indication for weight loss. The SUSTAIN trial program (semaglutide) and the SURPASS trial program (tirzepatide) demonstrated A1c reductions of 1.5 to 2.5 percentage points with weight loss of 5 to 15 percent at maximally tolerated doses. 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: - Diagnosis of T2D documented with ICD-10 E11.x - Current A1c, with date drawn (most plans want a result within the past 90 days) - Failure of or contraindication to metformin (or current metformin use that is no longer adequate) - Documented lifestyle intervention (medical nutrition therapy or diabetes self-management education) - Treatment goals (target A1c, target weight if relevant) Supporting evidence The clinical case for Ozempic (semaglutide) or Mounjaro (tirzepatide) in this indication is supported by the following registration trials and outcomes data: - SUSTAIN-6 (semaglutide cardiovascular outcomes in T2D) - REWIND (dulaglutide cardiovascular outcomes in T2D) - SURPASS-1 through SURPASS-5 (tirzepatide glycemic and weight outcomes) 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 Ozempic (semaglutide) or Mounjaro (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
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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