Carta de PA para Tricare: Recuperación de peso post-bariátrica.

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]

Tricare
Prior Authorization Department
Submitted via: Express Scripts Tricare (https://militaryrx.express-scripts.com) or fax 1-866-684-4488

Re: Prior Authorization Request, Wegovy or Zepbound
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 Tricare Prior Authorization Reviewer,

I am the treating clinician for [Patient name]. I am writing to request prior authorization for Wegovy or Zepbound for treatment of Post-bariatric weight regain (ICD-10: Z98.84, E66.01).

Clinical justification

Bariatric surgery is durable for most patients, but 20 to 50 percent experience clinically significant weight regain over the long term. Post-bariatric GLP-1 use has growing evidence: the 2024 BARI-OPTIMISE trial (Wegovy in patients with post-bariatric weight regain) demonstrated 8.8 percent mean weight loss versus 0.5 percent for placebo over 16 weeks. Post-bariatric status (ICD-10 Z98.84) does not exclude a patient from anti-obesity pharmacotherapy under any major plan's PA criteria; the qualifying criterion is current BMI plus comorbidities, regardless of how the patient reached that BMI.

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 Tricare policy

This request meets the criteria set out in Tricare Pharmacy Benefit, GLP-1 Receptor Agonists, current as of 2026:

  - Current BMI and the date measured
  - Type and date of prior bariatric procedure (Roux-en-Y, sleeve gastrectomy, gastric bypass, duodenal switch)
  - Documented post-surgical weight nadir and current weight to establish regain pattern
  - Comorbidity status (T2D, hypertension, dyslipidemia, OSA) using ICD-10 codes
  - Bariatric surgeon or obesity medicine specialist co-signing the letter when possible

Supporting evidence

The clinical case for Wegovy or Zepbound in this indication is supported by the following registration trials and outcomes data:

  - BARI-OPTIMISE (semaglutide 2.4 mg in post-bariatric weight regain), Mok et al. 2024
  - Pajecki et al. 2023 (liraglutide in post-bariatric regain)

Plan-specific note

Tricare is administered by Express Scripts. Tricare covers GLP-1 for T2D. As of 2026, Tricare covers Wegovy and Zepbound for obesity with BMI greater than or equal to 30 (or 27 with documented comorbidity) and documented six-month lifestyle intervention. Active-duty personnel may have additional readiness-related restrictions; coordinate with the military treatment facility pharmacy.

Requested action

I am requesting prior authorization for Wegovy or Zepbound 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