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Retatrutide A triple agonist peptide (GLP-1, GIP, glucagon receptor)

What payers require for Zepbound prior authorization Zepbound PA requirements are typically more stringent: Documented BMI of 30 or greater, or 27 or greater with at least one weight-related comorbidity Evidence of lifestyle intervention including documented participation in diet, exercise, and behavioral modification programs (usually for at least 3 to 6 months) Prior medication trials (some plans require documented failure of other weight management medications before approving tirzepatide) Specialist involvement (some plans require referral to or management by a bariatric medicine specialist, endocrinologist, or obesity medicine physician) Ongoing weight monitoring documentation with specific weight loss targets (typically 5% of baseline weight within 3 to 6 months of starting therapy) Patients researching BMI requirements for GLP-1 medications should understand that these thresholds directly correspond to the prior authorization criteria their provider must document

We also note that flexibilities for special statuses such as Non-patient facing are a feature of the Quality Payment Program overall

We are estimating a utilization of approximately 300,000 claims for the HCPCS code G0556, 1.3 million claims for the HCPCS code G0557, and 400,000 claims for the HCPCS code G0558, and solicited comment on our assumptions