Carta de PA para Kaiser Permanente: Indicación de riesgo cardiovascular (Wegovy SELECT).

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]

Kaiser Permanente
Prior Authorization Department
Submitted via: Kaiser internal provider EMR (KP HealthConnect)

Re: Prior Authorization Request, Wegovy (semaglutide 2.4 mg)
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 Kaiser Permanente Prior Authorization Reviewer,

I am the treating clinician for [Patient name]. I am writing to request prior authorization for Wegovy (semaglutide 2.4 mg) for treatment of Cardiovascular risk indication (Wegovy SELECT) (ICD-10: I25.10, I63.9, I50.9, E66.01).

Clinical justification

FDA approved Wegovy (semaglutide 2.4 mg) for cardiovascular risk reduction in adults with established cardiovascular disease and either obesity or overweight in March 2024, based on the SELECT trial. SELECT enrolled 17,604 adults with established cardiovascular disease and BMI greater than or equal to 27 without diabetes. Over a median 39.8 months of follow-up, Wegovy reduced the composite of cardiovascular death, nonfatal myocardial infarction or nonfatal stroke by 20 percent versus placebo (hazard ratio 0.80; published New England Journal of Medicine, November 2023). This is now a Medicare Part D-eligible indication independent of any obesity or T2D criteria.

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 Kaiser Permanente policy

This request meets the criteria set out in Kaiser Permanente Drug Formulary and internal Pharmacy and Therapeutics Committee guidance:

  - Established cardiovascular disease: prior MI (I21.x history), prior stroke or TIA (I63.x or G45.x) or established coronary artery disease (I25.x)
  - BMI greater than or equal to 27
  - No active T2D diagnosis required for this pathway (this is the obesity-or-overweight SELECT criteria, not the T2D pathway)
  - Cardiology or primary care attestation that patient is at elevated cardiovascular risk
  - Most recent imaging or cardiac event documentation

Supporting evidence

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

  - SELECT (Semaglutide Effects on Cardiovascular Outcomes in People with Overweight or Obesity), Lincoff et al., NEJM 2023

Plan-specific note

Kaiser is a closed-system HMO. PA is handled internally between your KP primary care physician and the regional formulary committee. Outside prescriptions are typically not honored. The Northern California, Southern California and Colorado regions each maintain a separate formulary. As of 2026, Kaiser has restricted GLP-1 for obesity to BMI greater than or equal to 35 with at least one comorbidity in most regions, with documented six-month lifestyle intervention.

Requested action

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