Carta de PA para Cigna: Obesity Class III (BMI 40 or higher).

La carta (copiar y editar)

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[Today's date]

Cigna
Prior Authorization Department
Submitted via: CoverMyMeds, Cigna provider portal or fax 1-866-873-8279

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 Cigna 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 Cigna policy

This request meets the criteria set out in Cigna Coverage Policy 1503 (GLP-1 Receptor Agonists for Obesity) and 1801 (GLP-1 RA for T2D):

  - 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

Cigna requires BMI greater than or equal to 30 (or 27 with comorbidity), three months of documented lifestyle modification and either step therapy through phentermine or contraindication. Express Scripts is the PBM for most Cigna commercial plans.

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

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