Cigna · Diabetes tipo 2 · Versión completa en inglés: /pa-letter/cigna--t2d/
Carta de PA para Cigna: 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: Cigna Coverage Policy 1503 (GLP-1 Receptor Agonists for Obesity) and 1801 (GLP-1 RA for T2D).
Nota del plan: 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.
Nota del plan: 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.
Lo que Express Scripts (Evernorth) realmente requiere
Cigna contrata la administración del beneficio de farmacia a Express Scripts (Evernorth), que adjudica esta PA. Los criterios siguientes provienen de la política clínica del PBM publicada públicamente. Cumpla cada uno antes de enviar.
- BMI greater than or equal to 30, OR BMI greater than or equal to 27 with at least one weight-related comorbidity
- Three months of documented lifestyle intervention (often more lenient than Caremark's six-month bar)
- Step therapy through phentermine for Cigna commercial; Tricare may waive step therapy for active-duty readiness
- Treatment plan with measurable weight-loss targets and follow-up monitoring
- SaveOnSP / SafeGuard Rx programs may exclude manufacturer coupons from copay accumulators, verify per plan
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] Cigna Prior Authorization Department Submitted via: CoverMyMeds, Cigna provider portal or fax 1-866-873-8279 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 Cigna 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 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): - 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 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 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.
Why you can trust GLP ChartSame scoring framework applied to every program. No paid placements. No removal of unfavorable information at advertiser request. Pricing is pulled from each program's public-facing page weekly.