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Medical Necessity Checklist for Formulary Exception If you're requesting a formulary exception, gather this documentation first: Required Documentation for Exception Request Current BMI documentation (30 or 27 with comorbidity) Documented comorbidities with ICD-10 codes: Obesity Class I/II/III (E66.811, E66.812, E66.813) Hypertension (I10) Type 2 Diabetes (E11) Dyslipidemia (E78.5) Obstructive Sleep Apnea (G47.33) Failed alternative treatments documented trials of: Phentermine or diethylpropion Qsymia or Contrave Semaglutide (Wegovy/Ozempic) for 6+ months Lifestyle modification records (diet/exercise program participation) Weight history showing chronic obesity (past 1-2 years) Letter of Medical Necessity from your Kaiser provider For more on prior auth documentation, see our Zepbound prior auth checklist EXCEPTION PATHWAYS How Some Members Get Coverage While standard coverage is limited, some Kaiser members do get Zepbound covered

Filippatos G, Anker SD, Agarwal R, Pitt B, Ruilope LM, Rossing P, et al

A total of 703 patients completed the 6-month double-blind phase

doi:10.1016/j.medcli.2018.11.019

North America Acetylcarnitine Market Restraints 3.2.1.3