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Prior Authorization Requirements Your provider must submit the Express Scripts PA form certifying: PA Documentation Checklist Required for TRICARE Zepbound Approval Current height and weight (within last 30 days) BMI calculation documented by provider 6-month lifestyle modification —actual documentation of diet/exercise program with insufficient weight loss Proof of step therapy —documented trial and failure (or contraindications) of at least one preferred drug Comorbidity diagnoses with ICD-10 codes: Obesity Class I (E66.811), Class II (E66.812), Class III (E66.813) Hypertension (I10) Dyslipidemia (E78.5) Obstructive Sleep Apnea (G47.33) No contraindications —confirmation of no MTC, MEN2, pancreatitis history Provider-completed Express Scripts PA form denied approved Honest Care helps patients fight back: Evidence-backed appeal letters — plus personalized guidance to appeal with confidence

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Quantity:10 Vials (Save 20%)

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