Carta de PA para Wellcare (Centene): Apnea obstructiva del sueño (indicación Zepbound SURMOUNT-OSA).

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]

Wellcare (Centene)
Prior Authorization Department
Submitted via: Wellcare provider portal, CoverMyMeds or fax 1-866-825-2884

Re: Prior Authorization Request, 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 Wellcare (Centene) Prior Authorization Reviewer,

I am the treating clinician for [Patient name]. I am writing to request prior authorization for Zepbound (tirzepatide) for treatment of Obstructive sleep apnea (Zepbound SURMOUNT-OSA indication) (ICD-10: G47.33).

Clinical justification

FDA approved Zepbound (tirzepatide) for the treatment of moderate-to-severe obstructive sleep apnea in adults with obesity in December 2024, based on the SURMOUNT-OSA trial program. SURMOUNT-OSA enrolled adults with moderate-to-severe OSA (AHI greater than or equal to 15 events per hour) and BMI greater than or equal to 30. At week 52, Zepbound reduced the apnea-hypopnea index by 25 to 29 events per hour versus 5 events per hour for placebo, with approximately 43 to 52 percent of treated patients achieving disease resolution (AHI less than 5 or AHI 5 to 14 with no daytime symptoms). This is the first GLP-1 indication for OSA and is a Medicare-eligible indication unlike pure obesity.

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 Wellcare (Centene) policy

This request meets the criteria set out in Wellcare Medicare Part D Formulary and PA Criteria, GLP-1 Receptor Agonists:

  - OSA diagnosed by polysomnography or home sleep apnea test with AHI greater than or equal to 15 (moderate to severe)
  - BMI greater than or equal to 30
  - Documentation of CPAP intolerance, non-adherence or patient preference (some plans require CPAP failure first; the FDA label does not require it)
  - Sleep medicine specialist involvement if the plan requires it
  - Most recent sleep study report attached

Supporting evidence

The clinical case for Zepbound (tirzepatide) in this indication is supported by the following registration trials and outcomes data:

  - SURMOUNT-OSA Study 1 (Zepbound in OSA patients on PAP therapy)
  - SURMOUNT-OSA Study 2 (Zepbound in OSA patients not on PAP therapy)

Plan-specific note

Wellcare is one of the largest Medicare Advantage and Part D carriers, owned by Centene. Medicare does not cover GLP-1 for pure obesity under federal statute, so Wegovy and Zepbound require the CV (SELECT) or OSA (SURMOUNT-OSA) FDA-labeled pathway on Wellcare Medicare lines. T2D pathway (Ozempic, Mounjaro) is covered with documented A1c and metformin trial. Express Scripts is the PBM for most Wellcare Medicare plans.

Requested action

I am requesting prior authorization for 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