Premera Blue Cross prior authorization letter for Obesity with one or more comorbidities.

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]

Premera Blue Cross
Prior Authorization Department
Submitted via: Premera provider portal or fax 1-888-742-1487

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 Premera Blue Cross 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 Obesity with one or more comorbidities (ICD-10: E66.01, E66.9, E66.811).

Clinical justification

Wegovy (semaglutide 2.4 mg) is indicated by FDA labeling for chronic weight management in adults with obesity (BMI greater than or equal to 30) or overweight (BMI greater than or equal to 27) with at least one weight-related comorbid condition. Zepbound (tirzepatide) carries the same labeling. The STEP-1 trial (Wegovy) demonstrated mean weight loss of 14.9 percent at 68 weeks. The SURMOUNT-1 trial (Zepbound) demonstrated mean weight loss of 22.5 percent at 72 weeks. Both trials enrolled the same patient population this PA is requesting.

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 Premera Blue Cross policy

This request meets the criteria set out in Premera Blue Cross Medical Policy 5.01.546, Anti-Obesity Medications:

  - Current weight, height, BMI (within the past 30 days)
  - Comorbidity diagnosis with supporting ICD-10 (hypertension I10, dyslipidemia E78.x, T2D E11.x, OSA G47.33, NAFLD K76.0)
  - Six months of documented lifestyle intervention (dietitian visits, structured program participation, prior anti-obesity medication trials)
  - Failure or contraindication for plans that require step therapy through phentermine or orlistat
  - Treatment plan: target weight loss, continued behavioral support, monitoring schedule

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 (Wegovy in adults with obesity)
  - STEP-3 (Wegovy with intensive behavioral therapy)
  - SURMOUNT-1 (Zepbound in adults with obesity)
  - SURMOUNT-4 (Zepbound continuation versus withdrawal)

Plan-specific note

Premera covers Wegovy and Zepbound at BMI greater than or equal to 30 (or 27 with comorbidity). Six months of documented lifestyle modification required. Step therapy through phentermine or orlistat may apply to some plan designs. Express Scripts is the PBM. Premera also administers some FEP BCBS lines in the Pacific Northwest; FEP members follow the FEHB BCBS policy. 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

Wegovy (semaglutide 2.4 mg) is indicated by FDA labeling for chronic weight management in adults with obesity (BMI greater than or equal to 30) or overweight (BMI greater than or equal to 27) with at least one weight-related comorbid condition. Zepbound (tirzepatide) carries the same labeling. The STEP-1 trial (Wegovy) demonstrated mean weight loss of 14.9 percent at 68 weeks. The SURMOUNT-1 trial (Zepbound) demonstrated mean weight loss of 22.5 percent at 72 weeks. Both trials enrolled the same patient population this PA is requesting.

ICD-10 codes to attach

• E66.01
• E66.9
• E66.811

Criteria checklist (what to attach with the letter)

1. Current weight, height, BMI (within the past 30 days)
2. Comorbidity diagnosis with supporting ICD-10 (hypertension I10, dyslipidemia E78.x, T2D E11.x, OSA G47.33, NAFLD K76.0)
3. Six months of documented lifestyle intervention (dietitian visits, structured program participation, prior anti-obesity medication trials)
4. Failure or contraindication for plans that require step therapy through phentermine or orlistat
5. Treatment plan: target weight loss, continued behavioral support, monitoring schedule

Supporting trials and evidence

• STEP-1 (Wegovy in adults with obesity)
• STEP-3 (Wegovy with intensive behavioral therapy)
• SURMOUNT-1 (Zepbound in adults with obesity)
• SURMOUNT-4 (Zepbound continuation versus withdrawal)

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.

• BMI just below 30 with no comorbidity documented
• No documentation of six-month lifestyle intervention
• No prior anti-obesity medication trial on plans that require step therapy
• Medicare plan (Medicare does not cover anti-obesity medications under federal statute; pivot to CV or OSA indication if appropriate)

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 Premera Blue Cross

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

Same indication, other plans

Same Obesity with one or more comorbidities indication, different plan-specific letter templates if your insurance is not Premera Blue Cross:

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