Carta de PA para Florida Blue: Type 2 diabetes with chronic kidney disease.

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]

Florida Blue
Prior Authorization Department
Submitted via: Availity provider portal or fax 1-877-265-5839

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 Florida Blue 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 with chronic kidney disease (ICD-10: E11.22, N18.3, N18.4, N18.5, N18.6).

Clinical justification

The KDIGO 2022 Clinical Practice Guideline for Diabetes Management in CKD names GLP-1 receptor agonists as a preferred second-line agent (after metformin and SGLT2 inhibitors) for patients with T2D and CKD, citing demonstrated renal-outcome benefit. The FLOW trial (semaglutide in T2D and CKD), published in NEJM in May 2024, randomized 3,533 adults with T2D and CKD (eGFR 25 to 75) to semaglutide 1.0 mg or placebo and demonstrated a 24 percent reduction in the composite kidney outcome (kidney failure, sustained eGFR decline of 50 percent or more, kidney or cardiovascular death) over a median 3.4 years. The ADA 2026 Standards of Care recommend GLP-1 RA independent of A1c for patients with T2D and CKD.

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 Florida Blue policy

This request meets the criteria set out in Florida Blue Medical Coverage Guideline 09-J0000-94, Anti-Obesity Pharmacotherapy:

  - Diagnosis of T2D documented with ICD-10 E11.22 (T2D with diabetic chronic kidney disease) or E11.x plus N18.x
  - Most recent eGFR and urine albumin-to-creatinine ratio (UACR), with dates drawn
  - CKD stage documented (N18.3 = stage 3, N18.4 = stage 4, N18.5 = stage 5, N18.6 = ESRD)
  - Current A1c (within the past 90 days)
  - Nephrology consult letter or documentation of nephrology co-management (strengthens but not always required)

Supporting evidence

The clinical case for Ozempic (semaglutide) or Mounjaro (tirzepatide) in this indication is supported by the following registration trials and outcomes data:

  - FLOW (semaglutide in T2D and CKD), Perkovic et al., NEJM 2024, DOI 10.1056/NEJMoa2403347
  - SUSTAIN-6 (semaglutide cardiovascular outcomes in T2D, included renal subgroup), Marso et al., NEJM 2016
  - AMPLITUDE-O (efpeglenatide in T2D with CV or kidney disease), Gerstein et al., NEJM 2021

Plan-specific note

Florida Blue covers Wegovy and Zepbound at BMI greater than or equal to 30 (or 27 with one weight-related comorbidity). Six months of structured lifestyle intervention required. Prime Therapeutics is the PBM for most Florida Blue commercial lines. ACA marketplace plans may have stricter step-therapy requirements through phentermine. Verify your specific plan's policy bulletin.

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

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