Prior authorization letters for GLP-1 medications

Your insurer's own criteria

19 of the 20 insurers we read state some prior authorization criteria on a web page. The first line of each is below; the insurer's page has the rest.

• Aetna: Aetna commercial PA policy 6450-C, the “BMI 35” weight-loss variant (page dated April 10, 2026), requires for adult weight loss a baseline BMI of 35 kg/m2 or more (documentation required; for patients switching from another weight-loss drug, the BMI at the start of any drug therapy counts). aetna.com
• Anthem Blue Cross and Blue Shield: CarelonRx (Elevance-owned PBM for Anthem) says it relies on evidence-based programs and policies, such as prior authorization criteria, to guide use of these drugs (GLP-1s) where there is clear evidence of clinical benefit. carelonrx.com
• Blue Cross and Blue Shield of Illinois: BCBSIL’s May 20, 2026 producer update says utilization management criteria apply to support appropriate, clinically driven use in groups that elect GLP-1 coverage for weight management. bcbsil.com
• Blue Shield of California: Jan. 28, 2026: depending on the large group plan, coverage for a member newly prescribed a weight loss drug may be limited to Class III obesity (BMI >= 40), or available at BMI >= 30 or BMI >= 27 with certain conditions. blueshieldca.com
• Cigna: Evernorth’s EncircleRx GLP-1 program (Evernorth is The Cigna Group’s health services division; Express Scripts is its PBM) requires a BMI of 32 or more, or 27 or more with two weight-related health issues. evernorth.com
• Florida Blue: Florida Blue’s provider bulletins page lists a January 2025 bulletin titled “GLP-1 Prior Authorization Requirement for Commercial Plans Effective April 1, 2025” (the bulletin itself is a PDF). floridablue.com
• Highmark: Under the policy in Highmark’s August 2024 bulletin (fully insured commercial and ACA plans), adults starting or staying on Saxenda, Wegovy or Zepbound needed a baseline BMI of 40 or more and at least two weight-related conditions. providers.highmark.com
• Humana: For the Medicare GLP-1 Bridge, Humana says the doctor submits a prior authorization and the prescription to a CMS central processor, which reviews eligibility and pays the claim. humana.com
• Kaiser Permanente: For FEHB members, Kaiser has prior authorization guidelines for GLP-1s prescribed for weight loss, and says they may vary by market. choose.kaiserpermanente.org
• Molina Healthcare: Molina Healthcare of Virginia (Medicaid) provider forms page lists a service authorization form for weight-loss management, updated September 2024. molinahealthcare.com
• Oscar Health: Oscar’s pharmacy clinical guidelines establish clinical criteria for utilization management decisions. hioscar.com
• Premera Blue Cross: Premera’s Feb. 12, 2026 newsletter says that for groups with the benefit, FDA-approved weight-loss GLP-1s such as Wegovy and Zepbound require prior authorization. producernews.premera.com
• UnitedHealthcare: UHC’s Medicare GLP-1 Bridge notice lists one CMS eligibility route as BMI of 30 or more with heart failure with preserved ejection fraction, uncontrolled hypertension, or chronic kidney disease stage 3a or above. uhcprovider.com
• Ambetter: For Wegovy’s heart-failure (HFpEF) indication, Ambetter’s policy (TX page, effective 2026-03-01) requires documented participation in a physician-directed weight loss program with diet, activity and behavior change. ambetterhealth.com
• Wellcare: GLP-1s may be covered under Part D for a Part D-covered indication, subject to the plan formulary and utilization management (PA, step therapy, quantity limits). wellcare.com
• TRICARE: Express Scripts (TRICARE pharmacy contractor) FAQ: this line introduces the list of conditions weight loss medications must meet under the TRICARE pharmacy benefit (the two items are the next two facts). militaryrx.express-scripts.com
• FEP Blue (federal employees): FEP Blue: a non-covered or excluded weight-loss GLP-1 can still be obtained if the provider submits a formulary exception request and the case aligns with the formulary exception guidelines. fepblue.org
• BlueCross BlueShield of South Carolina: BCBS SC (May 9, 2025) says all GLP-1 medications require prior authorization and are only authorized for FDA-approved uses. southcarolinablues.com
• CareFirst BlueCross BlueShield: CareFirst’s FEHB Noom Med FAQ says members must be 18 or older and meet one of two BMI conditions to be eligible for Noom Med. carefirst.com

Weight management

For: Zepbound, Wegovy (injection or tablets) or Foundayo. Approved use to reduce excess body weight and maintain weight reduction long term in adults with obesity or adults with overweight in the presence of at least one weight-related comorbid condition.dailymed.nlm.nih.gov, Sep 27, 2026

[Date]

To: [Health plan name], Pharmacy Prior Authorization
Re: [Patient name], date of birth [date], member ID [number]
Medication requested: [Zepbound (tirzepatide)], [dose], [how often]

I am requesting coverage of [Zepbound (tirzepatide)] for [patient name] for weight management. It is FDA-approved "to reduce excess body weight and maintain weight reduction long term in adults with obesity or adults with overweight in the presence of at least one weight-related comorbid condition."

Clinical information:
- Current BMI: [value] (measured [date]); BMI when GLP-1 therapy started: [value]
- Weight-related conditions: [for example hypertension, dyslipidemia, sleep apnea, prediabetes]
- Reduced-calorie diet and physical activity program: [describe, with start date]
- Weight-loss treatments tried before: [programs or medicines, dates, results]

In my clinical judgment this treatment is medically necessary for this patient because [reasons].
Chart notes supporting the above are attached. Please contact me at [phone] with any questions.

Sincerely,
[Prescriber name, credentials]
[NPI] [Practice name, address, phone, fax]

Obstructive sleep apnea

For: Zepbound. Approved use to treat moderate to severe obstructive sleep apnea (OSA) in adults with obesity.dailymed.nlm.nih.gov, Sep 27, 2026

[Date]

To: [Health plan name], Pharmacy Prior Authorization
Re: [Patient name], date of birth [date], member ID [number]
Medication requested: [Zepbound (tirzepatide)], [dose], [how often]

I am requesting coverage of [Zepbound (tirzepatide)] for [patient name] for obstructive sleep apnea. It is FDA-approved "to treat moderate to severe obstructive sleep apnea (OSA) in adults with obesity."

Clinical information:
- Sleep study: [date], apnea-hypopnea index (AHI) [value], severity [moderate or severe]
- Current BMI: [value] (measured [date])
- Current sleep apnea treatment: [for example CPAP, adherence]
- Reduced-calorie diet and physical activity program: [describe]

In my clinical judgment this treatment is medically necessary for this patient because [reasons].
Chart notes supporting the above are attached. Please contact me at [phone] with any questions.

Sincerely,
[Prescriber name, credentials]
[NPI] [Practice name, address, phone, fax]

Cardiovascular risk

For: Wegovy. Approved use to reduce the risk of major adverse cardiovascular (CV) events (CV death, non-fatal myocardial infarction, or non-fatal stroke) in adults with established CV disease and either obesity or overweight.dailymed.nlm.nih.gov, Sep 27, 2026

[Date]

To: [Health plan name], Pharmacy Prior Authorization
Re: [Patient name], date of birth [date], member ID [number]
Medication requested: [Wegovy (semaglutide)], [dose], [how often]

I am requesting coverage of [Wegovy (semaglutide)] for [patient name] for cardiovascular risk. It is FDA-approved "to reduce the risk of major adverse cardiovascular (CV) events (CV death, non-fatal myocardial infarction, or non-fatal stroke) in adults with established CV disease and either obesity or overweight."

Clinical information:
- Established cardiovascular disease: [for example prior heart attack or stroke, with dates]
- Current BMI: [value] (measured [date])
- Other cardiovascular treatment: [medicines]
- Reduced-calorie diet and physical activity program: [describe]

In my clinical judgment this treatment is medically necessary for this patient because [reasons].
Chart notes supporting the above are attached. Please contact me at [phone] with any questions.

Sincerely,
[Prescriber name, credentials]
[NPI] [Practice name, address, phone, fax]

MASH (fatty liver disease with fibrosis)

For: Wegovy injection. Approved use for the treatment of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH), formerly known as nonalcoholic steatohepatitis (NASH), with moderate to advanced liver fibrosis (consistent with stages F2 to F3 fibrosis) in adults. This indication is approved under accelerated approval based on improvement of MASH and fibrosis [see Clinical Studies (14.4)]. Continued approval for this indication may be contingent upon the verification and description of clinical benefit in a confirmatory trial.dailymed.nlm.nih.gov, Sep 27, 2026

[Date]

To: [Health plan name], Pharmacy Prior Authorization
Re: [Patient name], date of birth [date], member ID [number]
Medication requested: [Wegovy (semaglutide) injection], [dose], [how often]

I am requesting coverage of [Wegovy (semaglutide) injection] for [patient name] for mash (fatty liver disease with fibrosis). It is FDA-approved "for the treatment of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH), formerly known as nonalcoholic steatohepatitis (NASH), with moderate to advanced liver fibrosis (consistent with stages F2 to F3 fibrosis) in adults. This indication is approved under accelerated approval based on improvement of MASH and fibrosis [see Clinical Studies (14.4)]. Continued approval for this indication may be contingent upon the verification and description of clinical benefit in a confirmatory trial."

Clinical information:
- Diagnosis: noncirrhotic MASH, fibrosis stage [F2 or F3], how confirmed [biopsy or non-invasive tests, dates]
- Relevant results: [liver tests, imaging]
- Other treatment: [describe]

In my clinical judgment this treatment is medically necessary for this patient because [reasons].
Chart notes supporting the above are attached. Please contact me at [phone] with any questions.

Sincerely,
[Prescriber name, credentials]
[NPI] [Practice name, address, phone, fax]

Type 2 diabetes

For: Ozempic or Mounjaro. Approved use as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.dailymed.nlm.nih.gov, Sep 27, 2026

[Date]

To: [Health plan name], Pharmacy Prior Authorization
Re: [Patient name], date of birth [date], member ID [number]
Medication requested: [Ozempic (semaglutide)], [dose], [how often]

I am requesting coverage of [Ozempic (semaglutide)] for [patient name] for type 2 diabetes. It is FDA-approved "as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus."

Clinical information:
- Diagnosis: type 2 diabetes, since [year]
- Most recent A1C: [value] (date [date])
- Diabetes medicines tried: [names, doses, dates, results]
- Other conditions: [for example heart or kidney disease]

In my clinical judgment this treatment is medically necessary for this patient because [reasons].
Chart notes supporting the above are attached. Please contact me at [phone] with any questions.

Sincerely,
[Prescriber name, credentials]
[NPI] [Practice name, address, phone, fax]

Appeal a denial

Pick the letter that matches the reason in the denial letter, and answer it with the plan's own criteria. You have the right to appealIf your health plan refuses to pay a claim or ends your coverage, you have the right to appeal the decision and have it reviewed by a third party.healthcare.gov, Sep 29, 2026; if the plan says no again, an independent external review can be requestedA review of a plan's decision to deny coverage for or payment of a service by an independent third-party not related to the plan. If the plan denies an appeal, an external review can be requested.healthcare.gov, Sep 29, 2026. For a drug that is not on the plan's list, the request is an exceptionAn exception is when a drug plan decides to cover a drug that's not on its drug list, or to waive a coverage rule. A tiering exception is when a drug plan decides to charge a lower amount for a drug that's on its non-preferred drug tier (“Tiers” are described below.).medicare.gov, Sep 29, 2026.

[Date]

To: [Health plan name], Appeals
Re: Appeal of denial dated [date], reference number [number]
Patient: [name], date of birth [date], member ID [number]
Medication: [name, dose, how often]

I am appealing the denial of coverage for [medication] for [patient name].
The denial letter gives this reason: [quote the reason from the letter].

Why the plan's criteria are met:
- [Criterion from the plan's policy]: [how the patient meets it, with dates and values]
- [Criterion]: [evidence]

Attached: [chart notes, BMI history, sleep study or lab results, list of treatments tried, the plan's criteria].
I request that the plan reverse its decision. If it does not, please send the information needed to request an external review.
Please contact me at [phone] with any questions.

Sincerely,
[Prescriber name, credentials, NPI]

[Date]

To: [Health plan name], Appeals
Re: Appeal of denial dated [date], reference number [number]
Patient: [name], date of birth [date], member ID [number]
Medication: [name, dose, how often]

I am appealing the denial of coverage for [medication] for [patient name].
The denial letter gives this reason: [quote the reason from the letter].

I request a formulary exception. The covered alternatives on the plan's drug list are [names].
They are not appropriate for this patient because: [tried and failed, with dates / contraindicated / not approved for this use].

Attached: [chart notes, BMI history, sleep study or lab results, list of treatments tried, the plan's criteria].
I request that the plan reverse its decision. If it does not, please send the information needed to request an external review.
Please contact me at [phone] with any questions.

Sincerely,
[Prescriber name, credentials, NPI]

[Date]

To: [Health plan name], Appeals
Re: Appeal of denial dated [date], reference number [number]
Patient: [name], date of birth [date], member ID [number]
Medication: [name, dose, how often]

I am appealing the denial of coverage for [medication] for [patient name].
The denial letter gives this reason: [quote the reason from the letter].

The plan requires [drug] first. I request an exception to this step because:
- [The patient already tried it from (date) to (date); result: (result)]
- [or: it is contraindicated because (reason)] [or: it is not FDA-approved for (this use)]

Attached: [chart notes, BMI history, sleep study or lab results, list of treatments tried, the plan's criteria].
I request that the plan reverse its decision. If it does not, please send the information needed to request an external review.
Please contact me at [phone] with any questions.

Sincerely,
[Prescriber name, credentials, NPI]

[Date]

To: [Health plan name], Appeals
Re: Appeal of denial dated [date], reference number [number]
Patient: [name], date of birth [date], member ID [number]
Medication: [name, dose, how often]

I am appealing the denial of coverage for [medication] for [patient name].
The denial letter gives this reason: [quote the reason from the letter].

The plan's exclusion is for weight loss. This request is for a different FDA-approved use: [obstructive sleep apnea / cardiovascular risk reduction / MASH / type 2 diabetes].
The medication's label lists this use; the diagnosis is documented in the attached [sleep study / cardiology notes / liver results / A1C].

Attached: [chart notes, BMI history, sleep study or lab results, list of treatments tried, the plan's criteria].
I request that the plan reverse its decision. If it does not, please send the information needed to request an external review.
Please contact me at [phone] with any questions.

Sincerely,
[Prescriber name, credentials, NPI]

[Date]

To: [Health plan name], Appeals
Re: Appeal of denial dated [date], reference number [number]
Patient: [name], date of birth [date], member ID [number]
Medication: [name, dose, how often]

I am appealing the denial of coverage for [medication] for [patient name].
The denial letter gives this reason: [quote the reason from the letter].

The denial says [document] was missing. It is attached:
- [BMI measured on (date): (value); BMI when therapy started: (value)]
- [Lifestyle or weight-management program: (name), enrolled (date), participation (details)]

Attached: [chart notes, BMI history, sleep study or lab results, list of treatments tried, the plan's criteria].
I request that the plan reverse its decision. If it does not, please send the information needed to request an external review.
Please contact me at [phone] with any questions.

Sincerely,
[Prescriber name, credentials, NPI]

[Date]

To: [Health plan name], Appeals
Re: Appeal of denial dated [date], reference number [number]
Patient: [name], date of birth [date], member ID [number]
Medication: [name, dose, how often]

I am appealing the denial of coverage for [medication] for [patient name].
The denial letter gives this reason: [quote the reason from the letter].

This is a continuation request. The patient started on [date] at [weight / BMI] and is now [weight / BMI] ([percent] change).
[If the plan's renewal rule counts from the start of therapy, the start value above applies.] [Dose history: (doses and dates), including any supply interruptions.]
Stopping now would [clinical reasons].

Attached: [chart notes, BMI history, sleep study or lab results, list of treatments tried, the plan's criteria].
I request that the plan reverse its decision. If it does not, please send the information needed to request an external review.
Please contact me at [phone] with any questions.

Sincerely,
[Prescriber name, credentials, NPI]

[Date]

To: [Health plan name], Appeals
Re: Appeal of denial dated [date], reference number [number]
Patient: [name], date of birth [date], member ID [number]
Medication: [name, dose, how often]

I am appealing the denial of coverage for [medication] for [patient name].
The denial letter gives this reason: [quote the reason from the letter].

The prescribed dose, [dose], is within the FDA-approved dosing on the label. The plan's limit of [limit] does not allow [the maintenance dose / a 28-day supply].
I request an exception to the quantity limit for [period].

Attached: [chart notes, BMI history, sleep study or lab results, list of treatments tried, the plan's criteria].
I request that the plan reverse its decision. If it does not, please send the information needed to request an external review.
Please contact me at [phone] with any questions.

Sincerely,
[Prescriber name, credentials, NPI]

PCOS

No GLP-1 label lists polycystic ovary syndrome as an approved use. A request for someone with PCOS goes through a use that is on the label, most often weight management to reduce excess body weight and maintain weight reduction long term in adults with obesity or adults with overweight in the presence of at least one weight-related comorbid condition.dailymed.nlm.nih.gov, Sep 27, 2026: use the weight management letter above and list PCOS among the weight-related conditions. GLP-1s and PCOS.