GLP-1 Prior Authorization: the Criteria, the Clock, the Appeal

A denied GLP-1 prescription is not the end of the process, it is the start of one — and the whole thing runs on deadlines that are set in federal law rather than by your insurer. You have 180 days to appeal. They have 30 days to answer. If they say no again, an independent reviewer outside the company decides, and your insurer is bound by what that reviewer says.^[1][2]

Almost nobody uses this. The denial letter is written to sound final, the clock is not printed on it in bold, and most people read it as a verdict rather than as the first move.

The deadlines, in order

The step most people never reach

The internal appeal is the insurer reconsidering its own decision. External review is different in kind: an independent body outside the company looks at the case, and the insurer must comply with the result.^[2] It is not a request for goodwill and it does not depend on the insurer changing its mind.

One detail worth knowing, because it removes the most common obstacle: you can appoint someone to file it for you, and healthcare.gov names your doctor or another medical professional as an example of who that can be.^[2] The person best placed to argue the clinical case is allowed to make it directly.

What plans actually ask for

⚠ We do not publish plan-by-plan criteria, and pages that do go stale fast. Formularies are revised constantly and two people with the same insurer can sit under different employer groups with different rules, so a table of “what Aetna requires” is wrong for a large share of the people reading it. What is stable is the shape of the request. Plans draw from:

• A BMI threshold, commonly with a lower one accepted when a weight-related condition is present.
• A qualifying condition — type 2 diabetes, sleep apnea, cardiovascular disease, hypertension, prediabetes and so on, depending on the drug’s approved indications.
• Documented attempts at diet and exercise, sometimes over a stated period.
• Step therapy — evidence you tried a preferred drug first and it failed or was not tolerated.
• The prescriber’s attestation that the drug is part of a broader plan rather than issued alone.

For a criteria set that is fully public and does not change with your employer, the Medicare Bridge is the clearest worked example: a BMI of 35, or 30 with heart failure, uncontrolled hypertension or chronic kidney disease at stage 3a or higher, or 27 with prediabetes, a prior heart attack or stroke, or symptomatic peripheral artery disease — each judged at the point therapy started.^[3] Commercial plans are not bound by that, but it shows what a written criteria set looks like when you can read it in full.

Read the reason, then answer that reason

A denial is not one thing, and the fix depends entirely on which kind you got. The stated reason is on the written notice, and it usually falls into one of four groups.

That last row matters more than it looks. An exclusion is a contract term rather than a clinical judgment, and appealing it as though it were a medical dispute wastes the 180 days. Worth establishing which of the four you are facing before spending effort on the wrong one.

What it costs while you are appealing

An appeal can run 30 days on top of the original 15, and if it goes to external review, up to 45 more. That is a real gap, and it is worth knowing what the alternatives cost before you are in it rather than after.

Across the compounded prices in this register the cheapest semaglutide is $65 a month against a median of $189.99 over 481 recorded prices; for tirzepatide it is $83 against a median of $258 over 435. Manufacturer direct-pay programs for the approved products sit in a different band again. Our cash-market guide sets those side by side, and the coverage guide covers the approach before a denial happens.

Common questions