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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 (medical diagnosis codes): Obesity Class I/II/III (E66.811, E66.812, E66.813) Hypertension (I10) Type 2 Diabetes (E11) Dyslipidemia/high cholesterol (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 Wegovy prior authorization guide EXCEPTION PATHWAYS How Some Members Get Coverage While standard coverage is limited, some Kaiser members do get Wegovy covered

Impure products can contain: Incomplete synthesis fragments that may cause immune reactions Bacterial endotoxins from contaminated manufacturing Heavy metals from poor quality synthesis reagents Misidentified or substituted peptides entirely Degradation products from improper storage before sale Users who experience unusual or severe side effects should consider source quality as a potential cause

Resources like the retatrutide dosing guide and the 20mg dosing guide cover various scenarios in detail

Association of H19 promoter methylation with the expression of H19 and IGF-II genes in adrenocortical tumors