Zepbound prior authorization letter template

[Prescriber name, credentials]
[Practice name]
[Address] · [Phone] · [Fax]
NPI: [number]

[Date]

To: [Health plan or pharmacy benefit manager], Prior Authorization Department
Fax: [plan's prior authorization fax]

Re: Prior authorization request for Zepbound (tirzepatide) [single-dose pen / vial / KwikPen], [dose]
Patient: [full name] · Date of birth: [DOB]
Member ID: [ID] · Group: [group number]

I am writing to request coverage of Zepbound for my patient, [full name], for chronic weight management. Zepbound is FDA-approved, in combination with a reduced-calorie diet and increased physical activity, to reduce excess body weight and maintain weight reduction long term in adults with obesity or adults with overweight in the presence of at least one weight-related comorbid condition.

Clinical summary
- Current weight [weight] and height [height] on [date]; BMI [BMI] kg/m2.
- Baseline BMI before any weight-loss medication: [BMI] on [date].
- Weight-related conditions: [condition, ICD-10 code, date diagnosed]; [condition, ICD-10 code, date diagnosed].
- Weight-management program: [program or approach], from [start date] to [end date], including a reduced-calorie diet, increased physical activity and [behavioral counseling], documented in notes dated [dates]. Weight change during the program: [change].
- Previous weight-loss medications: [drug, dates, outcome or reason stopped], or none.
- I have reviewed the prescribing information, including contraindications and warnings, with the patient: [relevant notes].

Request
Please approve Zepbound [dose and form], [quantity] per [days supply], for [the initial approval period your policy allows]. Zepbound will be used together with the reduced-calorie diet and increased physical activity described above.

If another product is required first: the patient tried [drug] from [date] to [date] and stopped because of [reason], or cannot take it because [reason]. [Delete this paragraph if not needed.]

The patient meets your published criteria for this request: [restate the plan's own criteria and point to where each is documented in the enclosed notes].

Enclosed: chart notes documenting height, weight and BMI with dates; records of the weight-management program; medication history.

Please contact my office at [phone] with any questions or if further documentation is needed.

Sincerely,

[Prescriber signature]
[Prescriber name, credentials]