Carta de PA para Independence Blue Cross: MASH or NAFLD with obesity.

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]

Independence Blue Cross
Prior Authorization Department
Submitted via: NaviNet provider portal or fax 1-888-671-5285

Re: Prior Authorization Request, Wegovy (semaglutide 2.4 mg) or 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 Independence Blue Cross Prior Authorization Reviewer,

I am the treating clinician for [Patient name]. I am writing to request prior authorization for Wegovy (semaglutide 2.4 mg) or Zepbound (tirzepatide) for treatment of MASH or NAFLD with obesity (ICD-10: K76.0, K75.81, E66.9).

Clinical justification

Metabolic dysfunction-associated steatohepatitis (MASH, formerly known as NASH) and non-alcoholic fatty liver disease (NAFLD) are common comorbidities in patients with obesity and T2D. Under all major plan PA criteria, MASH or NAFLD documented by imaging, FibroScan or biopsy qualifies as a weight-related comorbidity, opening the obesity pathway at BMI greater than or equal to 27. The ESSENCE trial (semaglutide 2.4 mg in MASH), reported at AASLD 2024 and published in NEJM 2025, demonstrated histologic MASH resolution without worsening fibrosis in 62.9 percent of treated patients versus 34.3 percent on placebo at 72 weeks. The SYNERGY-NASH trial (tirzepatide in MASH) reported similar histologic benefit at 52 weeks. AASLD 2024 practice guidance names GLP-1 RA as appropriate pharmacotherapy in MASH when obesity coexists.

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 Independence Blue Cross policy

This request meets the criteria set out in Independence Blue Cross Medical Policy, Anti-Obesity Pharmacotherapy:

  - Current weight, height, BMI (BMI greater than or equal to 27 with MASH or NAFLD as the qualifying comorbidity)
  - MASH or NAFLD documented by FibroScan, ultrasound, MR elastography, MR-PDFF or liver biopsy
  - ICD-10 K76.0 (NAFLD) or K75.81 (MASH) attached
  - Most recent ALT, AST, GGT and lipid panel
  - Hepatology consult letter (strengthens but not always required)

Supporting evidence

The clinical case for Wegovy (semaglutide 2.4 mg) or Zepbound (tirzepatide) in this indication is supported by the following registration trials and outcomes data:

  - ESSENCE (semaglutide 2.4 mg in MASH), Sanyal et al., NEJM 2025
  - SYNERGY-NASH (tirzepatide in MASH), Loomba et al., NEJM 2024
  - Newsome et al. 2021 (semaglutide in NASH, phase 2), NEJM

Plan-specific note

Independence Blue Cross covers Wegovy and Zepbound for obesity at BMI greater than or equal to 30 (or 27 with one comorbidity from a defined list: T2D, hypertension, dyslipidemia, OSA, NAFLD). Requires documented six-month lifestyle intervention and step therapy through phentermine or orlistat where not contraindicated. FutureScripts is the PBM for most commercial lines. Verify your specific plan's policy bulletin before sending.

Requested action

I am requesting prior authorization for Wegovy (semaglutide 2.4 mg) or 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

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