Humana · Apnea obstructiva del sueño (indicación Zepbound SURMOUNT-OSA) · Versión completa en inglés: /pa-letter/humana--osa/
Carta de PA para Humana: Apnea obstructiva del sueño (indicación Zepbound SURMOUNT-OSA).
Plantilla defensible de carta para Zepbound (tirzepatide). FDA expanded Zepbound's label in December 2024 to include moderate-to-severe obstructive sleep apnea in adults with obesity. This is the first GLP-1 indication for OSA and opens a coverage path under Medicare.
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: Humana Pharmacy Solutions PA Criteria, GLP-1 Receptor Agonists.
Nota del plan: Humana is one of the largest Medicare Advantage and Part D carriers. Medicare Part D plans cover GLP-1 for T2D (Ozempic, Mounjaro) routinely and for cardiovascular indication (Wegovy under the SELECT label expansion) since 2024. Pure obesity indication is not covered under Medicare statutorily, so Wegovy and Zepbound for obesity require the CV or T2D path on a Medicare plan.
Nota del plan: Humana is one of the largest Medicare Advantage and Part D carriers. Medicare Part D plans cover GLP-1 for T2D (Ozempic, Mounjaro) routinely and for cardiovascular indication (Wegovy under the SELECT label expansion) since 2024. Pure obesity indication is not covered under Medicare statutorily, so Wegovy and Zepbound for obesity require the CV or T2D path on a Medicare plan.
La carta (copiar y editar)
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[Today's date] Humana Prior Authorization Department Submitted via: Humana provider portal, CoverMyMeds or fax 1-877-486-2621 Re: Prior Authorization Request, Zepbound (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 Humana Prior Authorization Reviewer, I am the treating clinician for [Patient name]. I am writing to request prior authorization for Zepbound (tirzepatide) for treatment of Obstructive sleep apnea (Zepbound SURMOUNT-OSA indication) (ICD-10: G47.33). Clinical justification FDA approved Zepbound (tirzepatide) for the treatment of moderate-to-severe obstructive sleep apnea in adults with obesity in December 2024, based on the SURMOUNT-OSA trial program. SURMOUNT-OSA enrolled adults with moderate-to-severe OSA (AHI greater than or equal to 15 events per hour) and BMI greater than or equal to 30. At week 52, Zepbound reduced the apnea-hypopnea index by 25 to 29 events per hour versus 5 events per hour for placebo, with approximately 43 to 52 percent of treated patients achieving disease resolution (AHI less than 5 or AHI 5 to 14 with no daytime symptoms). This is the first GLP-1 indication for OSA and is a Medicare-eligible indication unlike pure obesity. 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 Humana policy This request meets the criteria set out in Humana Pharmacy Solutions PA Criteria, GLP-1 Receptor Agonists: - OSA diagnosed by polysomnography or home sleep apnea test with AHI greater than or equal to 15 (moderate to severe) - BMI greater than or equal to 30 - Documentation of CPAP intolerance, non-adherence or patient preference (some plans require CPAP failure first; the FDA label does not require it) - Sleep medicine specialist involvement if the plan requires it - Most recent sleep study report attached Supporting evidence The clinical case for Zepbound (tirzepatide) in this indication is supported by the following registration trials and outcomes data: - SURMOUNT-OSA Study 1 (Zepbound in OSA patients on PAP therapy) - SURMOUNT-OSA Study 2 (Zepbound in OSA patients not on PAP therapy) Plan-specific note Humana is one of the largest Medicare Advantage and Part D carriers. Medicare Part D plans cover GLP-1 for T2D (Ozempic, Mounjaro) routinely and for cardiovascular indication (Wegovy under the SELECT label expansion) since 2024. Pure obesity indication is not covered under Medicare statutorily, so Wegovy and Zepbound for obesity require the CV or T2D path on a Medicare plan. Requested action I am requesting prior authorization for Zepbound (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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