UnitedHealthcare · MASH or NAFLD with obesity · Versión completa en inglés: /pa-letter/united-healthcare--mash-nafld/
Carta de PA para UnitedHealthcare: MASH or NAFLD with obesity.
Plantilla defensible de carta para Wegovy (semaglutide 2.4 mg) or Zepbound (tirzepatide). MASH (formerly NASH) and NAFLD with obesity qualify under the obesity-with-comorbidity pathway. Emerging evidence supports GLP-1 for hepatic outcomes.
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: OptumRx Prior Authorization Criteria, GLP-1 Receptor Agonists, last revised quarterly.
Nota del plan: OptumRx tightened criteria in 2025 to require BMI greater than or equal to 30 with one comorbidity OR BMI greater than or equal to 35, six months documented dietary intervention and step through phentermine or orlistat. Some employer carve-outs are stricter.
Nota del plan: OptumRx tightened criteria in 2025 to require BMI greater than or equal to 30 with one comorbidity OR BMI greater than or equal to 35, six months documented dietary intervention and step through phentermine or orlistat. Some employer carve-outs are stricter.
Lo que OptumRx realmente requiere
UnitedHealthcare contrata la administración del beneficio de farmacia a OptumRx, 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 with one comorbidity, OR BMI greater than or equal to 35 alone (post-2025 tightening)
- Six months of documented dietary intervention with structured weight-management program participation
- Step therapy through phentermine OR orlistat
- 6-month reauthorization checkpoint requiring documented weight loss greater than or equal to 4 percent from baseline
- Some employer carve-outs exclude obesity-indication GLP-1 entirely; check plan's specific formulary
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] UnitedHealthcare Prior Authorization Department Submitted via: OptumRx portal, UHC Link or fax 1-800-527-0531 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 UnitedHealthcare 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 MASH or NAFLD with obesity (ICD-10: K76.0, K75.81, E66.9). Clinical justification Metabolic dysfunction-associated steatohepatitis (MASH, formerly known as NASH) and non-alcoholic fatty liver disease (NAFLD) are common comorbidities in patients with obesity and T2D. Under all major plan PA criteria, MASH or NAFLD documented by imaging, FibroScan or biopsy qualifies as a weight-related comorbidity, opening the obesity pathway at BMI greater than or equal to 27. The ESSENCE trial (semaglutide 2.4 mg in MASH), reported at AASLD 2024 and published in NEJM 2025, demonstrated histologic MASH resolution without worsening fibrosis in 62.9 percent of treated patients versus 34.3 percent on placebo at 72 weeks. The SYNERGY-NASH trial (tirzepatide in MASH) reported similar histologic benefit at 52 weeks. AASLD 2024 practice guidance names GLP-1 RA as appropriate pharmacotherapy in MASH when obesity coexists. 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 UnitedHealthcare policy This request meets the criteria set out in OptumRx Prior Authorization Criteria, GLP-1 Receptor Agonists, last revised quarterly: - Current weight, height, BMI (BMI greater than or equal to 27 with MASH or NAFLD as the qualifying comorbidity) - MASH or NAFLD documented by FibroScan, ultrasound, MR elastography, MR-PDFF or liver biopsy - ICD-10 K76.0 (NAFLD) or K75.81 (MASH) attached - Most recent ALT, AST, GGT and lipid panel - Hepatology consult letter (strengthens but not always required) 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: - ESSENCE (semaglutide 2.4 mg in MASH), Sanyal et al., NEJM 2025 - SYNERGY-NASH (tirzepatide in MASH), Loomba et al., NEJM 2024 - Newsome et al. 2021 (semaglutide in NASH, phase 2), NEJM Plan-specific note OptumRx tightened criteria in 2025 to require BMI greater than or equal to 30 with one comorbidity OR BMI greater than or equal to 35, six months documented dietary intervention and step through phentermine or orlistat. Some employer carve-outs are stricter. 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.
Why you can trust GLP ChartSame scoring framework applied to every program. No paid placements. No removal of unfavorable information at advertiser request. Pricing is pulled from each program's public-facing page weekly.