Carta de PA para Florida Blue: Diabetes tipo 2.

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 (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 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.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

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