Guide

GLP-1 Prior Authorization: What Plans Ask For and How to Prepare

Prior authorization is a documentation exercise, not a clinical argument. Plans publish criteria; approval turns on whether your record contains the specific elements tho

What prior authorization actually is

A requirement that your plan approve a drug before it will pay. The plan publishes criteria, your prescriber submits documentation, and a reviewer decides whether the documentation matches.

That framing matters because it tells you where to put effort. Most denials are not the plan disagreeing that you need the drug. They are the submission failing to contain something the criteria require, in a form the reviewer could find.

Get the criteria first

Ask your plan for the prior-authorization criteria for the specific drug, in writing. Many publish them; all will provide them on request. This single step changes the exercise from guessing to matching.

Read them literally. If the criteria name a BMI threshold with a comorbidity, the submission needs both documented, with dates. If they require a documented trial of lifestyle intervention over a stated period, a note saying "patient has tried diet and exercise" will not satisfy it.

What criteria commonly require

These vary by plan and this is not a checklist to submit — it is what to expect so you can ask your prescriber whether your record covers it.

• BMI thresholds, often with an alternative lower threshold where a weight-related comorbidity is present.
• Documented comorbidity, coded, not described in narrative.
• Prior lifestyle intervention, frequently with a duration requirement.
• Step therapy — a documented trial of a preferred alternative, with the outcome recorded.
• Baseline measurements with dates in the record.
• Exclusion screening, notably personal or family history of medullary thyroid carcinoma or MEN 2, which are contraindications on the label.

Where submissions fail

Missing dates. A criterion requiring six months of documented intervention needs entries showing that period, not a summary written today.

Narrative instead of codes. Reviewers work from structured data. A comorbidity described in free text may not register.

The wrong indication. If your plan covers a molecule for diabetes and not for weight management, submitting under the weight-management indication produces a denial that is procedurally correct.

Step therapy unaddressed. If a preferred alternative exists, the submission needs to say what happened when it was tried, or why it is contraindicated.

What you can usefully do

Bring your prescriber the written criteria. Ask directly whether your record contains each element and, where it does not, what would be needed. Ask who at the practice handles prior authorizations — in many, it is a specific administrator rather than the clinician, and reaching them saves weeks.

Keep your own copy of what was submitted and when. If it is denied, you appeal against a specific document, and you will want to know what the reviewer actually saw.

Timelines

Standard determinations typically run days to a couple of weeks; expedited review exists where a delay would jeopardise health, and your prescriber requests it. If a decision is overdue, call and cite the date of submission. Plans have deadlines and they are enforceable.

If it is denied

A first-level denial is routinely overturned on appeal, particularly where the denial was documentary rather than clinical. See the appeal guide, and request the denial reason in writing before doing anything else.

Questions readers actually ask