Getting a GLP-1 prior authorization approved

What prior authorization is

Prior authorization, or PA, means your insurer must approve a drug before it will pay. Your prescriber's office sends a form with your medical details, and the plan decides.

First, check whether your plan covers the drug at all. Many employer plans exclude weight-loss drugs entirely, and no PA can override an exclusion. Look up the drug on your plan's formulary.

What insurers commonly ask for

• A recorded height, weight and BMI, often within the last 30 to 90 days
• Weight-related conditions documented with diagnosis codes, if your BMI is 27 to 29.9
• A record of earlier diet, exercise or weight-management program attempts
• Proof you tried other drugs first, called step therapy
• For type 2 diabetes drugs, a diagnosis and often an A1c result
• For renewals, proof of results, often a minimum percent weight loss

Criteria vary by plan, and they change. Ask for your plan's written policy for the specific drug.

Common denial reasons and fixes

Appeal letter outline

Your prescriber usually writes this, but you can draft it to save time. Keep it to one page.

1. Your name, date of birth, member ID and claim or reference number
2. The drug, dose and the date of the denial
3. A one-line request: "Please reconsider the denial of coverage for [drug]."
4. Your diagnosis, BMI and each weight-related condition
5. Treatments already tried, with dates and results
6. How the denial criteria are met, point by point, using the plan's own policy wording
7. Your prescriber's statement of medical necessity
8. A list of attached records: chart notes, labs, weigh-in log

If the internal appeal fails, most plans allow an external review by an independent reviewer. Your denial letter must explain how to request one.

Coverage terms worth knowing

• Formulary: your plan's list of covered drugs, usually sorted into tiers that set your copay
• Exclusion: a drug or drug class the plan won't cover at all; weight-loss drugs are a common one
• Step therapy: trying a cheaper drug first before the plan pays for another
• Quantity limit: a cap on how much the plan pays for per fill, such as 4 pens a month
• Formulary exception: a request to cover a drug that isn't on the list, based on medical need
• Peer-to-peer review: a call between your prescriber and the plan's reviewing doctor
• External review: an independent review after the plan's own appeals are used up

Knowing the right term helps on the phone. Ask, for example, "Is this a formulary exclusion or a prior authorization denial?" The answer tells you which path to take.

Tips that speed things up

• Ask the pharmacy or office for the exact denial reason in writing
• Keep a weigh-in log; the weigh-in tracker exports one
• Note every call: date, name and reference number
• Ask whether a peer-to-peer review between your doctor and the plan is possible

Drug pages have plan-specific notes: Zepbound insurance, Wegovy insurance. While you wait, compare out-of-pocket options in the cost index.

When to call your doctor

• As soon as you get a denial, so the office can resubmit or appeal
• If a coverage gap means you'll miss doses, to plan a safe restart