Premera Blue Cross prior authorization letter for Type 2 diabetes with chronic kidney disease.

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, Ozempic (semaglutide) or Mounjaro (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 Ozempic (semaglutide) or Mounjaro (tirzepatide) for treatment of Type 2 diabetes with chronic kidney disease (ICD-10: E11.22, N18.3, N18.4, N18.5, N18.6).

Clinical justification

The KDIGO 2022 Clinical Practice Guideline for Diabetes Management in CKD names GLP-1 receptor agonists as a preferred second-line agent (after metformin and SGLT2 inhibitors) for patients with T2D and CKD, citing demonstrated renal-outcome benefit. The FLOW trial (semaglutide in T2D and CKD), published in NEJM in May 2024, randomized 3,533 adults with T2D and CKD (eGFR 25 to 75) to semaglutide 1.0 mg or placebo and demonstrated a 24 percent reduction in the composite kidney outcome (kidney failure, sustained eGFR decline of 50 percent or more, kidney or cardiovascular death) over a median 3.4 years. The ADA 2026 Standards of Care recommend GLP-1 RA independent of A1c for patients with T2D and CKD.

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:

  - Diagnosis of T2D documented with ICD-10 E11.22 (T2D with diabetic chronic kidney disease) or E11.x plus N18.x
  - Most recent eGFR and urine albumin-to-creatinine ratio (UACR), with dates drawn
  - CKD stage documented (N18.3 = stage 3, N18.4 = stage 4, N18.5 = stage 5, N18.6 = ESRD)
  - Current A1c (within the past 90 days)
  - Nephrology consult letter or documentation of nephrology co-management (strengthens but not always required)

Supporting evidence

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

  - FLOW (semaglutide in T2D and CKD), Perkovic et al., NEJM 2024, DOI 10.1056/NEJMoa2403347
  - SUSTAIN-6 (semaglutide cardiovascular outcomes in T2D, included renal subgroup), Marso et al., NEJM 2016
  - AMPLITUDE-O (efpeglenatide in T2D with CV or kidney disease), Gerstein et al., NEJM 2021

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 Ozempic (semaglutide) or Mounjaro (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

The KDIGO 2022 Clinical Practice Guideline for Diabetes Management in CKD names GLP-1 receptor agonists as a preferred second-line agent (after metformin and SGLT2 inhibitors) for patients with T2D and CKD, citing demonstrated renal-outcome benefit. The FLOW trial (semaglutide in T2D and CKD), published in NEJM in May 2024, randomized 3,533 adults with T2D and CKD (eGFR 25 to 75) to semaglutide 1.0 mg or placebo and demonstrated a 24 percent reduction in the composite kidney outcome (kidney failure, sustained eGFR decline of 50 percent or more, kidney or cardiovascular death) over a median 3.4 years. The ADA 2026 Standards of Care recommend GLP-1 RA independent of A1c for patients with T2D and CKD.

ICD-10 codes to attach

• E11.22
• N18.3
• N18.4
• N18.5
• N18.6

Criteria checklist (what to attach with the letter)

1. Diagnosis of T2D documented with ICD-10 E11.22 (T2D with diabetic chronic kidney disease) or E11.x plus N18.x
2. Most recent eGFR and urine albumin-to-creatinine ratio (UACR), with dates drawn
3. CKD stage documented (N18.3 = stage 3, N18.4 = stage 4, N18.5 = stage 5, N18.6 = ESRD)
4. Current A1c (within the past 90 days)
5. Nephrology consult letter or documentation of nephrology co-management (strengthens but not always required)

Supporting trials and evidence

• FLOW (semaglutide in T2D and CKD), Perkovic et al., NEJM 2024, DOI 10.1056/NEJMoa2403347
• SUSTAIN-6 (semaglutide cardiovascular outcomes in T2D, included renal subgroup), Marso et al., NEJM 2016
• AMPLITUDE-O (efpeglenatide in T2D with CV or kidney disease), Gerstein et al., NEJM 2021

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.

• eGFR not documented or older than 90 days
• PA submitted for Wegovy or Zepbound (obesity-indication brands) rather than Ozempic or Mounjaro (the T2D brands of the same molecule)
• Plan asks for SGLT2 inhibitor trial first; cite KDIGO 2022 which allows either drug class as second-line for CKD

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 Ozempic:

• 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 Type 2 diabetes with chronic kidney disease 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