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E66.3 for overweight) An ICD-10 code for the qualifying tier condition, where applicable The prescribing clinician's National Provider Identifier (NPI) and a statement that they are not on the CMS Preclusion List Documentation that the medication will be used alongside structured nutrition and physical activity Date of last clinical visit with the prescribing provider The specific medication being requested (Wegovy, Zepbound, or Foundayo) with dose and quantity Some Part D plans add requirements such as documented prior lifestyle intervention attempts, weight history over the past 24 months, or signed patient acknowledgment of the long-term nature of treatment
