Carta de PA para Oscar Health: Prediabetes with progression risk.

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]

Oscar Health
Prior Authorization Department
Submitted via: Oscar provider portal or fax 1-844-279-7869

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 Oscar Health 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 Prediabetes with progression risk (ICD-10: R73.03, E66.9).

Clinical justification

Prediabetes (A1c 5.7 to 6.4 percent, fasting glucose 100 to 125 mg/dL or 2-hour OGTT 140 to 199 mg/dL) affects approximately 38 percent of US adults and progresses to T2D at an annual rate of 5 to 10 percent without intervention. Under the obesity-with-comorbidity PA pathway, prediabetes is recognized as a qualifying comorbidity at BMI greater than or equal to 27. The STEP-1 trial showed that 84 percent of participants with prediabetes at baseline reverted to normoglycemia at 68 weeks on semaglutide 2.4 mg. The SURMOUNT-1 trial subgroup analysis (Jastreboff et al., NEJM 2022) found similar reversion rates on tirzepatide. The 2024 ADA Standards of Care recommend considering pharmacotherapy in prediabetes when lifestyle intervention has not produced adequate response, particularly when BMI is greater than or equal to 30.

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 (BMI greater than or equal to 27 with prediabetes as the qualifying comorbidity)
  - Documented A1c 5.7 to 6.4 or fasting glucose 100 to 125 or 2-hour OGTT 140 to 199 (within the past 90 days)
  - ICD-10 R73.03 (prediabetes) attached
  - Six months of documented lifestyle intervention (medical nutrition therapy or structured program)
  - Family history of T2D, gestational diabetes history or other progression-risk factors documented in the chart

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:

  - STEP-1 prediabetes subgroup (semaglutide 2.4 mg), Wilding et al., NEJM 2021
  - SURMOUNT-1 prediabetes subgroup (tirzepatide), Jastreboff et al., NEJM 2022
  - Diabetes Prevention Program (lifestyle, metformin, comparator data), Knowler et al., NEJM 2002

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 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