Highmark Blue Cross Blue Shield prior authorization letter for Prediabetes with progression risk.

The letter (copy and edit)

Copy the body below and paste it into your clinician's portal or word processor. Replace every [BRACKET] placeholder with patient-specific data before sending. The letter is from your clinician to the plan, signed by your clinician.

[Today's date]

Highmark Blue Cross Blue Shield
Prior Authorization Department
Submitted via: NaviNet provider portal or fax 1-866-240-8123

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 Highmark Blue Cross Blue Shield 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 Prediabetes with progression risk (ICD-10: R73.03, E66.9).

Clinical justification

Prediabetes (A1c 5.7 to 6.4 percent, fasting glucose 100 to 125 mg/dL or 2-hour OGTT 140 to 199 mg/dL) affects approximately 38 percent of US adults and progresses to T2D at an annual rate of 5 to 10 percent without intervention. Under the obesity-with-comorbidity PA pathway, prediabetes is recognized as a qualifying comorbidity at BMI greater than or equal to 27. The STEP-1 trial showed that 84 percent of participants with prediabetes at baseline reverted to normoglycemia at 68 weeks on semaglutide 2.4 mg. The SURMOUNT-1 trial subgroup analysis (Jastreboff et al., NEJM 2022) found similar reversion rates on tirzepatide. The 2024 ADA Standards of Care recommend considering pharmacotherapy in prediabetes when lifestyle intervention has not produced adequate response, particularly when BMI is greater than or equal to 30.

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 Highmark Blue Cross Blue Shield policy

This request meets the criteria set out in Highmark Medical Policy I-115, Anti-Obesity Pharmacotherapy:

  - Current weight, height, BMI (BMI greater than or equal to 27 with prediabetes as the qualifying comorbidity)
  - Documented A1c 5.7 to 6.4 or fasting glucose 100 to 125 or 2-hour OGTT 140 to 199 (within the past 90 days)
  - ICD-10 R73.03 (prediabetes) attached
  - Six months of documented lifestyle intervention (medical nutrition therapy or structured program)
  - Family history of T2D, gestational diabetes history or other progression-risk factors documented in the chart

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 prediabetes subgroup (semaglutide 2.4 mg), Wilding et al., NEJM 2021
  - SURMOUNT-1 prediabetes subgroup (tirzepatide), Jastreboff et al., NEJM 2022
  - Diabetes Prevention Program (lifestyle, metformin, comparator data), Knowler et al., NEJM 2002

Plan-specific note

Highmark covers Wegovy and Zepbound at BMI greater than or equal to 30 (or 27 with comorbidity). Six months of documented lifestyle intervention required. Highmark Medicare Advantage plans follow CMS rules, meaning pure obesity is not covered; pivot to CV (SELECT) or OSA (SURMOUNT-OSA) pathway. Express Scripts is the PBM for most Highmark commercial plans. 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)

Clinical rationale for this indication

Prediabetes (A1c 5.7 to 6.4 percent, fasting glucose 100 to 125 mg/dL or 2-hour OGTT 140 to 199 mg/dL) affects approximately 38 percent of US adults and progresses to T2D at an annual rate of 5 to 10 percent without intervention. Under the obesity-with-comorbidity PA pathway, prediabetes is recognized as a qualifying comorbidity at BMI greater than or equal to 27. The STEP-1 trial showed that 84 percent of participants with prediabetes at baseline reverted to normoglycemia at 68 weeks on semaglutide 2.4 mg. The SURMOUNT-1 trial subgroup analysis (Jastreboff et al., NEJM 2022) found similar reversion rates on tirzepatide. The 2024 ADA Standards of Care recommend considering pharmacotherapy in prediabetes when lifestyle intervention has not produced adequate response, particularly when BMI is greater than or equal to 30.

ICD-10 codes to attach

• R73.03
• E66.9

Criteria checklist (what to attach with the letter)

1. Current weight, height, BMI (BMI greater than or equal to 27 with prediabetes as the qualifying comorbidity)
2. Documented A1c 5.7 to 6.4 or fasting glucose 100 to 125 or 2-hour OGTT 140 to 199 (within the past 90 days)
3. ICD-10 R73.03 (prediabetes) attached
4. Six months of documented lifestyle intervention (medical nutrition therapy or structured program)
5. Family history of T2D, gestational diabetes history or other progression-risk factors documented in the chart

Supporting trials and evidence

• STEP-1 prediabetes subgroup (semaglutide 2.4 mg), Wilding et al., NEJM 2021
• SURMOUNT-1 prediabetes subgroup (tirzepatide), Jastreboff et al., NEJM 2022
• Diabetes Prevention Program (lifestyle, metformin, comparator data), Knowler et al., NEJM 2002

The denial reasons to preempt

Most denials of this combination cite one of the reasons below. Address each one in the patient-specific findings section before you send. If the plan denies anyway, the appeal letter cites the same evidence with the denial reason added in the opening paragraph.

• A1c not documented or older than 90 days
• BMI is below 27 (does not meet the obesity-with-comorbidity pathway floor)
• Plan classifies prediabetes as not a qualifying comorbidity; cite the ADA 2024 standards and the STEP-1 reversion data

If you have not picked a program yet

The PA path is faster when your prescriber is already familiar with your insurance plan and runs the authorization regularly. Programs in our chart that actively run prior authorization for Wegovy:

• PlushCare · commercial and Medicare PA experience
• Form Health · obesity-medicine specialty, high PA success rate
• Knownwell · cardiometabolic focus, all major PBMs
• Calibrate · insurance-focused, employer-friendly

Other indications under Highmark Blue Cross Blue Shield

If this indication is not the right fit, try a different qualifying indication under the same plan:

Same indication, other plans

Same Prediabetes with progression risk indication, different plan-specific letter templates if your insurance is not Highmark Blue Cross Blue Shield:

Disclaimer

John Samaras, Founder and editorI started GLP Chart after overpaying for a GLP-1 myself. Based in Austin, Texas. About this site · LinkedIn · Contact