Oscar Health · Obesity Class III (BMI 40 or higher) · Versión completa en inglés: /pa-letter/oscar-health--obesity-class-3/
Carta de PA para Oscar Health: Obesity Class III (BMI 40 or higher).
Plantilla defensible de carta para Zepbound (tirzepatide) or Wegovy (semaglutide 2.4 mg). BMI 40 or higher meets the most defensible threshold for anti-obesity pharmacotherapy under every major plan's PA criteria. No comorbidity is required at this BMI.
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: Oscar Clinical Guideline, Anti-Obesity Pharmacotherapy.
Nota del plan: Oscar Health covers Wegovy and Zepbound for obesity at BMI greater than or equal to 30 (or 27 with one weight-related comorbidity). Six months of documented lifestyle intervention required. Step therapy through phentermine where not contraindicated. CVS Caremark is the PBM for most Oscar commercial lines. ACA marketplace tier plans (Bronze, Silver) may exclude anti-obesity medications entirely; verify your specific plan's formulary before submitting.
Nota del plan: Oscar Health covers Wegovy and Zepbound for obesity at BMI greater than or equal to 30 (or 27 with one weight-related comorbidity). Six months of documented lifestyle intervention required. Step therapy through phentermine where not contraindicated. CVS Caremark is the PBM for most Oscar commercial lines. ACA marketplace tier plans (Bronze, Silver) may exclude anti-obesity medications entirely; verify your specific plan's formulary before submitting.
Lo que CVS Caremark realmente requiere
Oscar Health contrata la administración del beneficio de farmacia a CVS Caremark, que adjudica esta PA. Los criterios siguientes provienen de la política clínica del PBM publicada públicamente. Cumpla cada uno antes de enviar.
- BMI greater than or equal to 30, OR BMI greater than or equal to 27 with at least one weight-related comorbidity (T2D, hypertension, dyslipidemia, OSA)
- Documented six-month lifestyle intervention or prior anti-obesity medication trial
- Step therapy through phentermine or orlistat (or documented contraindication / intolerance)
- Treatment plan including continued lifestyle counseling and 5 percent weight-loss target at 6 months
- Reauthorization requires documented adherence and ≥5 percent weight loss from baseline at 12 months
La carta (copiar y editar)
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[Today's date] Oscar Health Prior Authorization Department Submitted via: Oscar provider portal or fax 1-844-279-7869 Re: Prior Authorization Request, Zepbound (tirzepatide) or 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 Oscar Health Prior Authorization Reviewer, I am the treating clinician for [Patient name]. I am writing to request prior authorization for Zepbound (tirzepatide) or Wegovy (semaglutide 2.4 mg) for treatment of Obesity Class III (BMI 40 or higher) (ICD-10: E66.01, E66.811, Z68.41, Z68.42, Z68.43, Z68.44, Z68.45). Clinical justification Obesity Class III (BMI greater than or equal to 40, ICD-10 E66.01) is the highest-severity category in the standard obesity classification and qualifies for FDA-labeled anti-obesity pharmacotherapy regardless of comorbidity status. The SURMOUNT-1 trial (Zepbound) enrolled adults with mean BMI 38, and a pre-specified subgroup with BMI greater than or equal to 35 achieved 25.0 percent mean weight loss at 72 weeks on the 15 mg dose. The STEP-1 trial (Wegovy) enrolled adults with mean BMI 37.9 and demonstrated 14.9 percent mean weight loss at 68 weeks. Class III obesity carries the highest comorbidity burden (T2D, OSA, hypertension, dyslipidemia, NAFLD, joint disease) and the highest mortality risk among obesity categories, supporting the strongest case for pharmacotherapy as part of a comprehensive treatment plan. 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 Oscar Health policy This request meets the criteria set out in Oscar Clinical Guideline, Anti-Obesity Pharmacotherapy: - Current weight, height, BMI (within the past 30 days) documenting BMI greater than or equal to 40 - ICD-10 Z68.4x code corresponding to BMI category (Z68.41 = 40-44.9, Z68.42 = 45-49.9, Z68.43 = 50-59.9, Z68.44 = 60-69.9, Z68.45 = 70+) - Six months of documented lifestyle intervention (dietitian visits, structured program participation, or prior anti-obesity medication trials) - Treatment plan: target weight loss, continued behavioral support, monitoring schedule - Consideration of bariatric surgery (documented discussion or contraindication strengthens the case) Supporting evidence The clinical case for Zepbound (tirzepatide) or Wegovy (semaglutide 2.4 mg) in this indication is supported by the following registration trials and outcomes data: - SURMOUNT-1 (Zepbound in adults with obesity), Jastreboff et al., NEJM 2022, DOI 10.1056/NEJMoa2206038 - STEP-1 (Wegovy in adults with obesity), Wilding et al., NEJM 2021, DOI 10.1056/NEJMoa2032183 - SURMOUNT-4 (Zepbound continuation versus withdrawal), Aronne et al., JAMA 2024 Plan-specific note Oscar Health covers Wegovy and Zepbound for obesity at BMI greater than or equal to 30 (or 27 with one weight-related comorbidity). Six months of documented lifestyle intervention required. Step therapy through phentermine where not contraindicated. CVS Caremark is the PBM for most Oscar commercial lines. ACA marketplace tier plans (Bronze, Silver) may exclude anti-obesity medications entirely; verify your specific plan's formulary before submitting. Requested action I am requesting prior authorization for Zepbound (tirzepatide) or 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
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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