Wellcare (Centene) · Recuperación de peso post-bariátrica · Versión completa en inglés: /pa-letter/wellcare--post-bariatric/
Carta de PA para Wellcare (Centene): Recuperación de peso post-bariátrica.
Plantilla defensible de carta para Wegovy or Zepbound. Patients with weight regain after bariatric surgery qualify under the obesity indication if current BMI is 30 or above (or 27 with comorbidity). Surgical history is supportive, not exclusionary.
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: Wellcare Medicare Part D Formulary and PA Criteria, GLP-1 Receptor Agonists.
Nota del plan: 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.
Nota del plan: 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.
Lo que Express Scripts (Evernorth) realmente requiere
Wellcare (Centene) 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] Wellcare (Centene) Prior Authorization Department Submitted via: Wellcare provider portal, CoverMyMeds or fax 1-866-825-2884 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 Wellcare (Centene) 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 Wellcare (Centene) policy This request meets the criteria set out in Wellcare Medicare Part D Formulary and PA Criteria, GLP-1 Receptor Agonists: - 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 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 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
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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