Medicare Advantage (generic letter) prior authorization letter for Cardiovascular risk indication (Wegovy SELECT).

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]

Medicare Advantage (generic letter)
Prior Authorization Department
Submitted via: Plan-specific portal or CoverMyMeds

Re: Prior Authorization Request, Wegovy (semaglutide 2.4 mg)
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 Medicare Advantage (generic letter) Prior Authorization Reviewer,

I am the treating clinician for [Patient name]. I am writing to request prior authorization for Wegovy (semaglutide 2.4 mg) for treatment of Cardiovascular risk indication (Wegovy SELECT) (ICD-10: I25.10, I63.9, I50.9, E66.01).

Clinical justification

FDA approved Wegovy (semaglutide 2.4 mg) for cardiovascular risk reduction in adults with established cardiovascular disease and either obesity or overweight in March 2024, based on the SELECT trial. SELECT enrolled 17,604 adults with established cardiovascular disease and BMI greater than or equal to 27 without diabetes. Over a median 39.8 months of follow-up, Wegovy reduced the composite of cardiovascular death, nonfatal myocardial infarction or nonfatal stroke by 20 percent versus placebo (hazard ratio 0.80; published New England Journal of Medicine, November 2023). This is now a Medicare Part D-eligible indication independent of any obesity or T2D criteria.

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 Medicare Advantage (generic letter) policy

This request meets the criteria set out in Plan-specific Medicare Advantage formulary and PA criteria:

  - Established cardiovascular disease: prior MI (I21.x history), prior stroke or TIA (I63.x or G45.x) or established coronary artery disease (I25.x)
  - BMI greater than or equal to 27
  - No active T2D diagnosis required for this pathway (this is the obesity-or-overweight SELECT criteria, not the T2D pathway)
  - Cardiology or primary care attestation that patient is at elevated cardiovascular risk
  - Most recent imaging or cardiac event documentation

Supporting evidence

The clinical case for Wegovy (semaglutide 2.4 mg) in this indication is supported by the following registration trials and outcomes data:

  - SELECT (Semaglutide Effects on Cardiovascular Outcomes in People with Overweight or Obesity), Lincoff et al., NEJM 2023

Plan-specific note

Medicare does not cover GLP-1 for obesity indication under federal statute (the 2003 MMA exclusion). For patients with documented type 2 diabetes, Medicare Advantage plans cover Ozempic and Mounjaro under the T2D indication. For patients with established cardiovascular disease and obesity or overweight, Medicare Advantage plans may cover Wegovy under the SELECT FDA-labeled cardiovascular indication (approved March 2024). For patients with moderate-to-severe obstructive sleep apnea and obesity, Medicare Advantage plans may cover Zepbound under the SURMOUNT-OSA FDA-labeled OSA indication (approved December 2024). The CV and OSA pathways follow FDA labeling and are evaluated against the plan's medical-necessity criteria for each indication.

Requested action

I am requesting prior authorization for Wegovy (semaglutide 2.4 mg) 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

FDA approved Wegovy (semaglutide 2.4 mg) for cardiovascular risk reduction in adults with established cardiovascular disease and either obesity or overweight in March 2024, based on the SELECT trial. SELECT enrolled 17,604 adults with established cardiovascular disease and BMI greater than or equal to 27 without diabetes. Over a median 39.8 months of follow-up, Wegovy reduced the composite of cardiovascular death, nonfatal myocardial infarction or nonfatal stroke by 20 percent versus placebo (hazard ratio 0.80; published New England Journal of Medicine, November 2023). This is now a Medicare Part D-eligible indication independent of any obesity or T2D criteria.

ICD-10 codes to attach

• I25.10
• I63.9
• I50.9
• E66.01

Criteria checklist (what to attach with the letter)

1. Established cardiovascular disease: prior MI (I21.x history), prior stroke or TIA (I63.x or G45.x) or established coronary artery disease (I25.x)
2. BMI greater than or equal to 27
3. No active T2D diagnosis required for this pathway (this is the obesity-or-overweight SELECT criteria, not the T2D pathway)
4. Cardiology or primary care attestation that patient is at elevated cardiovascular risk
5. Most recent imaging or cardiac event documentation

Supporting trials and evidence

• SELECT (Semaglutide Effects on Cardiovascular Outcomes in People with Overweight or Obesity), Lincoff et al., NEJM 2023

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.

• Cardiovascular history not clearly documented with ICD-10 codes
• BMI is below 27
• Patient already on Ozempic for T2D (which is the same molecule under a different brand and lower dose; some plans push to optimize Ozempic dose first)

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 Medicare Advantage (generic letter)

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

Same indication, other plans

Same Cardiovascular risk indication (Wegovy SELECT) indication, different plan-specific letter templates if your insurance is not Medicare Advantage (generic letter):

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