Premera Blue Cross · Obesidad con una o más comorbilidades · Versión completa en inglés: /pa-letter/premera-blue-cross--obesity-with-comorbidity/
Carta de PA para Premera Blue Cross: Obesidad con una o más comorbilidades.
Plantilla defensible de carta para Wegovy (semaglutide 2.4 mg) or Zepbound (tirzepatide). BMI 30 or higher, OR BMI 27 or higher with at least one weight-related comorbidity (T2D, hypertension, dyslipidemia, OSA). Documented six-month lifestyle intervention.
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: Premera Blue Cross Medical Policy 5.01.546, Anti-Obesity Medications.
Nota del plan: Premera covers Wegovy and Zepbound at BMI greater than or equal to 30 (or 27 with comorbidity). Six months of documented lifestyle modification required. Step therapy through phentermine or orlistat may apply to some plan designs. Express Scripts is the PBM. Premera also administers some FEP BCBS lines in the Pacific Northwest; FEP members follow the FEHB BCBS policy. Verify your specific plan's policy.
Nota del plan: Premera covers Wegovy and Zepbound at BMI greater than or equal to 30 (or 27 with comorbidity). Six months of documented lifestyle modification required. Step therapy through phentermine or orlistat may apply to some plan designs. Express Scripts is the PBM. Premera also administers some FEP BCBS lines in the Pacific Northwest; FEP members follow the FEHB BCBS policy. Verify your specific plan's policy.
Lo que Express Scripts (Evernorth) realmente requiere
Premera Blue Cross contrata la administración del beneficio de farmacia a Express Scripts (Evernorth), 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
- Three months of documented lifestyle intervention (often more lenient than Caremark's six-month bar)
- Step therapy through phentermine for Cigna commercial; Tricare may waive step therapy for active-duty readiness
- Treatment plan with measurable weight-loss targets and follow-up monitoring
- SaveOnSP / SafeGuard Rx programs may exclude manufacturer coupons from copay accumulators, verify per plan
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] Premera Blue Cross Prior Authorization Department Submitted via: Premera provider portal or fax 1-888-742-1487 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 Premera 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 Obesity with one or more comorbidities (ICD-10: E66.01, E66.9, E66.811). Clinical justification Wegovy (semaglutide 2.4 mg) is indicated by FDA labeling for chronic weight management in adults with obesity (BMI greater than or equal to 30) or overweight (BMI greater than or equal to 27) with at least one weight-related comorbid condition. Zepbound (tirzepatide) carries the same labeling. The STEP-1 trial (Wegovy) demonstrated mean weight loss of 14.9 percent at 68 weeks. The SURMOUNT-1 trial (Zepbound) demonstrated mean weight loss of 22.5 percent at 72 weeks. Both trials enrolled the same patient population this PA is requesting. 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 Premera Blue Cross policy This request meets the criteria set out in Premera Blue Cross Medical Policy 5.01.546, Anti-Obesity Medications: - Current weight, height, BMI (within the past 30 days) - Comorbidity diagnosis with supporting ICD-10 (hypertension I10, dyslipidemia E78.x, T2D E11.x, OSA G47.33, NAFLD K76.0) - Six months of documented lifestyle intervention (dietitian visits, structured program participation, prior anti-obesity medication trials) - Failure or contraindication for plans that require step therapy through phentermine or orlistat - Treatment plan: target weight loss, continued behavioral support, monitoring schedule 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 (Wegovy in adults with obesity) - STEP-3 (Wegovy with intensive behavioral therapy) - SURMOUNT-1 (Zepbound in adults with obesity) - SURMOUNT-4 (Zepbound continuation versus withdrawal) Plan-specific note Premera covers Wegovy and Zepbound at BMI greater than or equal to 30 (or 27 with comorbidity). Six months of documented lifestyle modification required. Step therapy through phentermine or orlistat may apply to some plan designs. Express Scripts is the PBM. Premera also administers some FEP BCBS lines in the Pacific Northwest; FEP members follow the FEHB BCBS policy. Verify your specific plan's policy. 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
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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