Insurance Prior Authorization for GLP-1: Step-by-Step

What prior authorization means

Prior authorization (PA) is a process where an insurance plan requires your prescriber to obtain approval before they will cover a medication. It is the plan’s way of checking whether the medication meets their coverage criteria before they agree to pay for it. It does not mean you cannot get the medication — it means your prescriber has to make the case first.

GLP-1 medications like Wegovy, Ozempic, Mounjaro, and Zepbound are among the most expensive drugs on the market, which is why most commercial plans require PA. The criteria differ by plan and by which indication you are seeking coverage for (type 2 diabetes versus obesity, for example).

The PA is initiated by your prescriber’s office, not by you. Your role is to make sure your prescriber has complete information and to follow up to make sure the request was actually submitted. Delays often happen because the PA request is sitting in a queue at the doctor’s office or the insurer, not because it was denied.

Required documentation

While requirements vary by plan, the following information is typically needed for a GLP-1 prior authorization. Helping your prescriber compile this can speed things up:

• Diagnosis codes (ICD-10): for obesity, this is usually E66.01 or E66.9; for type 2 diabetes, E11.x. The specific code matters because plans may cover the medication for one indication but not another.
• BMI documentation: most plans require a documented BMI of 30 or higher (or 27+ with a qualifying comorbidity). The BMI should come from a clinical measurement in a recent office visit, not self-reported.
• Comorbidities: conditions like hypertension, type 2 diabetes, dyslipidemia, or sleep apnea can qualify you for coverage even at a lower BMI. Documentation from your chart is needed.
• Prior treatment history: many plans require documentation that you tried a structured dietary program, other medications, or both before approving a GLP-1. Your prescriber may need to write a letter explaining the clinical history.
• Letter of medical necessity: a signed statement from your prescriber explaining why the medication is appropriate for your specific clinical situation. The more specific and clinically detailed this is, the better.

Ask your prescriber’s office who manages PA requests and whether there is a dedicated staff member for this. Many larger practices have a prior authorization coordinator.

The appeal process

A denial is not the end. Members have appealed and won — sometimes more than once. The key steps:

1. Request the denial letter in writing. Insurers are required to provide the specific reason for denial. “Not medically necessary” is not a complete explanation — ask for the clinical criteria they applied.
2. Have your prescriber request a peer-to-peer review. This is a direct phone call between your doctor and the insurer’s medical reviewer. Members consistently report that peer-to-peer calls can turn a denial into an approval, especially when the reviewing physician has more clinical context. Your prescriber’s office has to initiate this — ask them explicitly.
3. Submit a formal internal appeal. Include any additional documentation that addresses the denial reason — updated BMI records, more detailed notes from office visits, letters addressing specific criteria. Most plans have a 30- to 60-day window for internal appeals.
4. External independent review. If the internal appeal is denied, most states require that you have access to an external independent review by a medical professional who is not employed by the insurer. This option is usually listed in the denial letter.
5. State insurance commissioner complaint. If the plan is subject to state regulation (most commercial plans are; self-funded employer plans may be ERISA-governed), a complaint to your state insurance commissioner can sometimes prompt the insurer to reconsider.

How members have succeeded

Forum discussions on prior authorization reveal a few patterns in successful approvals and appeals:

• Detailed, specific letters of medical necessity that tie the medication to documented conditions, prior treatment attempts, and the specific clinical criteria in the denial letter perform better than generic template letters.
• Prescribers who do peer-to-peer reviews have significantly better outcomes than those who submit paperwork only. If your prescriber’s office will not do peer-to-peer reviews, this is worth a direct conversation.
• Getting a referral to an obesity medicine specialist or endocrinologist, if your current prescriber is a primary care physician, sometimes helps — specialist letters carry weight with reviewers.
• Documenting everything. Keep records of every submission, every conversation, every reference number. If you escalate, having a paper trail is essential.
• Manufacturer patient assistance programs. Novo Nordisk and Eli Lilly both have programs for eligible patients. While navigating the PA, their support lines can sometimes help with submission strategy for their specific products.

Compounded alternatives while appealing

Some members start or continue with compounded semaglutide or tirzepatide from a licensed compounding pharmacy while waiting for a brand PA to be resolved. This is a personal decision with trade-offs:

• Compounded products are not FDA-approved and do not carry the same quality or safety oversight as brand-name drugs.
• They are often significantly less expensive out of pocket than paying brand list price during an appeal period.
• Starting on a compounded product does not typically affect your ability to switch to a brand product once PA is approved.
• If you go this route, use only a reputable, licensed 503A or 503B pharmacy and keep your prescriber informed.

This is a decision to make with your prescriber, not independently. The brand vs compounded comparison page covers the trade-offs in more detail.