Wellcare (Centene) prior authorization letter for Obesity Class III (BMI 40 or higher).
A defensible, plan-specific letter template for Zepbound (tirzepatide) or Wegovy (semaglutide 2.4 mg). BMI 40 or higher meets the most defensible threshold for anti-obesity pharmacotherapy under every major plan's PA criteria. No comorbidity is required at this BMI.
Plan 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.
Wellcare (Centene) contracts pharmacy benefit administration to Express Scripts (Evernorth), which adjudicates this PA. The criteria below are pulled from the publicly posted PBM clinical policy. Match each item before you send.
- 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
Full Express Scripts (Evernorth)routing & portal details → · Source: Express Scripts (Evernorth)clinical policy → (verified May 25)
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] Wellcare (Centene) Prior Authorization Department Submitted via: Wellcare provider portal, CoverMyMeds or fax 1-866-825-2884 Re: Prior Authorization Request, Zepbound (tirzepatide) or 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 Wellcare (Centene) Prior Authorization Reviewer, I am the treating clinician for [Patient name]. I am writing to request prior authorization for Zepbound (tirzepatide) or Wegovy (semaglutide 2.4 mg) for treatment of Obesity Class III (BMI 40 or higher) (ICD-10: E66.01, E66.811, Z68.41, Z68.42, Z68.43, Z68.44, Z68.45). Clinical justification Obesity Class III (BMI greater than or equal to 40, ICD-10 E66.01) is the highest-severity category in the standard obesity classification and qualifies for FDA-labeled anti-obesity pharmacotherapy regardless of comorbidity status. The SURMOUNT-1 trial (Zepbound) enrolled adults with mean BMI 38, and a pre-specified subgroup with BMI greater than or equal to 35 achieved 25.0 percent mean weight loss at 72 weeks on the 15 mg dose. The STEP-1 trial (Wegovy) enrolled adults with mean BMI 37.9 and demonstrated 14.9 percent mean weight loss at 68 weeks. Class III obesity carries the highest comorbidity burden (T2D, OSA, hypertension, dyslipidemia, NAFLD, joint disease) and the highest mortality risk among obesity categories, supporting the strongest case for pharmacotherapy as part of a comprehensive treatment plan. 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 weight, height, BMI (within the past 30 days) documenting BMI greater than or equal to 40 - ICD-10 Z68.4x code corresponding to BMI category (Z68.41 = 40-44.9, Z68.42 = 45-49.9, Z68.43 = 50-59.9, Z68.44 = 60-69.9, Z68.45 = 70+) - Six months of documented lifestyle intervention (dietitian visits, structured program participation, or prior anti-obesity medication trials) - Treatment plan: target weight loss, continued behavioral support, monitoring schedule - Consideration of bariatric surgery (documented discussion or contraindication strengthens the case) Supporting evidence The clinical case for Zepbound (tirzepatide) or Wegovy (semaglutide 2.4 mg) in this indication is supported by the following registration trials and outcomes data: - SURMOUNT-1 (Zepbound in adults with obesity), Jastreboff et al., NEJM 2022, DOI 10.1056/NEJMoa2206038 - STEP-1 (Wegovy in adults with obesity), Wilding et al., NEJM 2021, DOI 10.1056/NEJMoa2032183 - SURMOUNT-4 (Zepbound continuation versus withdrawal), Aronne et al., JAMA 2024 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 Zepbound (tirzepatide) or 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
Obesity Class III (BMI greater than or equal to 40, ICD-10 E66.01) is the highest-severity category in the standard obesity classification and qualifies for FDA-labeled anti-obesity pharmacotherapy regardless of comorbidity status. The SURMOUNT-1 trial (Zepbound) enrolled adults with mean BMI 38, and a pre-specified subgroup with BMI greater than or equal to 35 achieved 25.0 percent mean weight loss at 72 weeks on the 15 mg dose. The STEP-1 trial (Wegovy) enrolled adults with mean BMI 37.9 and demonstrated 14.9 percent mean weight loss at 68 weeks. Class III obesity carries the highest comorbidity burden (T2D, OSA, hypertension, dyslipidemia, NAFLD, joint disease) and the highest mortality risk among obesity categories, supporting the strongest case for pharmacotherapy as part of a comprehensive treatment plan.
ICD-10 codes to attach
E66.01E66.811Z68.41Z68.42Z68.43Z68.44Z68.45
Criteria checklist (what to attach with the letter)
- Current weight, height, BMI (within the past 30 days) documenting BMI greater than or equal to 40
- ICD-10 Z68.4x code corresponding to BMI category (Z68.41 = 40-44.9, Z68.42 = 45-49.9, Z68.43 = 50-59.9, Z68.44 = 60-69.9, Z68.45 = 70+)
- Six months of documented lifestyle intervention (dietitian visits, structured program participation, or prior anti-obesity medication trials)
- Treatment plan: target weight loss, continued behavioral support, monitoring schedule
- Consideration of bariatric surgery (documented discussion or contraindication strengthens the case)
Supporting trials and evidence
- SURMOUNT-1 (Zepbound in adults with obesity), Jastreboff et al., NEJM 2022, DOI 10.1056/NEJMoa2206038
- STEP-1 (Wegovy in adults with obesity), Wilding et al., NEJM 2021, DOI 10.1056/NEJMoa2032183
- SURMOUNT-4 (Zepbound continuation versus withdrawal), Aronne et al., JAMA 2024
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.
- No Z68.4x BMI ICD-10 code attached
- No documentation of six-month lifestyle intervention
- Medicare plan (Medicare does not cover anti-obesity medications under federal statute; pivot to CV, OSA or T2D indication if applicable)
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 Zepbound:
- 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 Wellcare (Centene)
If this indication is not the right fit, try a different qualifying indication under the same plan:
Same indication, other plans
Same Obesity Class III (BMI 40 or higher) indication, different plan-specific letter templates if your insurance is not Wellcare (Centene):
Disclaimer
Educational templates only. Not legal or medical advice. Letters must be signed by a treating clinician (MD, DO, NP, PA) with prescribing authority. Each plan changes criteria quarterly. Verify against your plan's most recent PA policy bulletin before sending. Do not fabricate clinical findings. Do not alter a clinician's signature.
