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

A denied GLP-1 prescription is the start of a process, not the end of one, and that process runs on deadlines 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]

Few people use this. Medicare Advantage enrollees appealed 11.5% of denied prior authorization requests in 2024, and marketplace enrollees appealed fewer than 1% of denied claims.^[4][5] The denial letter is written to sound final, the clock is not printed on it in bold, and it is easy to 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 does not depend on the insurer changing its mind.

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 ask for

We have read the 2026 criteria several large insurers publish, in our pages on UnitedHealthcare’s Zepbound and Wegovy rules, Cigna’s and the Blue Cross companies’, and even those need rereading every few months. 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, such as type 2 diabetes, sleep apnea, cardiovascular disease, hypertension or prediabetes, depending on the drug’s approved indications. A drug approved only for diabetes, such as Rybelsus, is not approved for weight loss on its own.
• Documented attempts at diet and exercise, sometimes over a stated period, such as the six months Aetna asks for.
• Step therapy, meaning 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. It has three tiers, each judged at the point therapy started. A BMI of 35 qualifies alone. At 30, you also need heart failure, uncontrolled hypertension or stage 3a+ kidney disease. At 27, you need prediabetes, a past stroke or myocardial infarction, or peripheral artery disease that causes symptoms. Type 2 diabetes, moderate-to-severe sleep apnea and fatty liver disease exclude you outright.^[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. A drug left off a formulary is different again: a formulary exception can still win it, as with Zepbound on CVS Caremark plans. Establish 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, so it helps to know what the alternatives cost before you are in it.

When we measured in August 2026, the cheapest compounded semaglutide in this register was $65 a month against a median of $189.99 over 481 recorded prices; for tirzepatide it was $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.

Some telehealth services work the insurance side while an appeal runs, and we keep a board of the sellers that say they accept or coordinate insurance. Roen Rx helps members seek coverage for brand Ozempic, Wegovy, Zepbound and Mounjaro, with compounded drugs as a fallback, and Hello Alpha bills brand GLP-1s to your own insurance under a monthly clinician membership. JRNYS does not bill insurance itself but steers insured members to brand-name drugs at their own pharmacy. If your employer or plan sponsors it, FlyteHealth offers physician-led care that prescribes a GLP-1 only when it fits.

In six states, TeleSlim Clinic builds its plan around this step: its obesity-medicine doctors prescribe FDA-approved drugs only, offer prior authorization help and send the prescription to your own pharmacy. If insurance denies the drug and you choose not to pay cash, you are charged only for the first visit and the plan fees are refunded.

Others sell both forms for cash, so a bridge on compounded medication does not have to mean changing prescribers if the brand is later approved. RxION Health, WePeptideRx and AlyveRx list brand Wegovy beside compounded semaglutide; AlyveRx also sells the compounded drug as sublingual drops and does not use insurance. Nucific lists brand Zepbound and Ozempic next to its compounded and microdosed versions.

Common questions