A letter of medical necessity (LOMN) is typically written by a healthcare professional on behalf of patients to compel insurance companies to cover the cost of a care intervention such as pharmacotherapy. It often contains the same information that is needed in appeal letters or prior authorizations. 

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Please feel free to use this form to generate a draft Letter of Medical Necessity for Zepbound (tirzepatide) for overweight/obesity that you can share with your healthcare team to advocate for access to tirzepatide. This form was created in anticipation of upcoming formulary changes on July 1, 2025 that may affect you if you have CVS Caremark as a pharmacy benefits manager (PBM). 

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Note: TriOS does not operate under a system officially compliant with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, which governs the protection of personal health information. Information submitted through this form is stored securely within a Wix-hosted database and is accessible only to a limited number of authorized TriOS staff members. By submitting this form, you acknowledge and accept these conditions and waive any right to pursue legal action against TriOS related to the collection, storage, or handling of the submitted information.