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

By Nora Bissett, Pricing Editor (https://glpwatchdog.org/authors/nora-bissett) | Published: 2026-08-16 | Updated: 2026-10-30

Canonical page: https://glpwatchdog.org/research/glp1-prior-authorization-and-appeals

> You have 180 days to appeal a denied GLP-1 prescription and your insurer has 30 to answer. If they refuse again, an independent reviewer decides and the insurer is bound by it. The federal deadlines, verified.

## Key points

- 180 days to file an internal appeal; the insurer has 30 to decide it if you have not had the drug yet.
- External review: file within 4 months, decided within 45 days (72 hours expedited), and the insurer is BOUND by the result.
- You may appoint a representative to file for you, and healthcare.gov names your doctor as an example.
- An exclusion is a contract term, not a clinical judgment. Appealing it as a medical dispute wastes the 180 days.

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.

> **What this page covers.** These are the federal deadlines that apply to commercial and marketplace plans. Medicare Part D runs a separate appeals track on its own timetable. We could not verify those deadlines against a working government source when we last checked, so we do not state them here. If you are on Medicare, start with [the Medicare GLP-1 Bridge](https://glpwatchdog.org/research/medicare-glp1-bridge), where authorization goes through a single central processor.

## The deadlines, in order

*Federal timelines for commercial and marketplace plans*

| Stage | Who acts | Deadline |
| --- | --- | --- |
| Decision on a prior authorization | Insurer | **15 days** (72 hours for urgent care) |
| Decision on care already received | Insurer | 30 days |
| File an internal appeal | **You** | **Within 180 days** of the denial notice |
| Decide the internal appeal | Insurer | **30 days** if you have not had the drug yet; 60 days if you have |
| File for external review | **You** | **Within 4 months** of the final denial |
| Decide the external review | Independent reviewer | No later than **45 days**; **72 hours** if expedited |

> **The two deadlines that are yours are the two people miss.** You have 180 days to appeal and 4 months to escalate. Both run from when the notice reaches you, not from when you get around to opening it. Everything else on the table is an obligation the insurer owes you. Your own clock is the one that runs out silently.

## 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.

> **A denial delivered by phone is not a decision yet.** A final internal decision may be given verbally, but it has to be followed by written notice within **48 hours**.[1] Get it in writing regardless. The written notice is what carries the stated reason, and the stated reason is what you are appealing against.

## What plans ask for

We have read the 2026 criteria several large insurers publish, in our pages on [UnitedHealthcare’s Zepbound and Wegovy rules](https://glpwatchdog.org/research/does-unitedhealthcare-cover-zepbound-and-wegovy), [Cigna’s](https://glpwatchdog.org/research/does-cigna-cover-zepbound-and-wegovy) and [the Blue Cross companies’](https://glpwatchdog.org/research/does-blue-cross-cover-zepbound-and-wegovy), 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](https://glpwatchdog.org/research/glp1-for-prediabetes), depending on the drug’s approved indications. A drug approved only for diabetes, such as [Rybelsus](https://glpwatchdog.org/research/rybelsus-for-weight-loss), 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](https://glpwatchdog.org/research/does-aetna-cover-zepbound-and-wegovy).
- **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](https://glpwatchdog.org/research/glp1-and-blood-pressure) or stage 3a+ kidney disease. At 27, you need prediabetes, a past stroke or myocardial infarction, or [peripheral artery disease](https://glpwatchdog.org/research/how-far-you-can-walk) 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.

> **Ask your plan for its criteria in writing before the request goes in.** They are usually published as a coverage policy or a prior-authorization form, and reading them first turns the submission from a guess into a checklist. Our [prior-authorization letter generator](https://glpwatchdog.org/tools/glp1-prior-auth-letter-generator) assembles a request against those categories for your prescriber to review and adapt.

## 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.

*What the denial is telling you*

| The reason given | What it means you do next |
| --- | --- |
| Missing documentation | Often the most fixable — supply what was absent. Often it never needed an appeal at all. |
| Criteria not met | Establish which specific criterion, and whether your record actually fails it or simply did not evidence it. |
| Step therapy required | Document the earlier drug and why it failed or was not tolerated — or request an exception on medical grounds. |
| **Excluded from the plan** | The hardest. The plan does not cover this drug class at all, so no amount of evidence satisfies a criterion that does not exist. This is where the cash market becomes the real comparison. |

That last row matters more than it looks. An exclusion is [a contract term rather than a clinical judgment](https://glpwatchdog.org/research/does-blue-cross-cover-zepbound-and-wegovy), 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](https://glpwatchdog.org/research/cvs-caremark-zepbound-coverage). 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](https://glpwatchdog.org/research/what-drives-compounded-glp1-prices) 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](https://glpwatchdog.org/research/cheapest-glp1-without-insurance) sets those side by side, and [the coverage guide](https://glpwatchdog.org/research/how-to-get-a-glp1-covered-by-insurance) 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](https://glpwatchdog.org/best/glp1-providers-that-take-insurance). [Roen Rx](https://glpwatchdog.org/reviews/roen-rx) helps members seek coverage for brand Ozempic, Wegovy, Zepbound and Mounjaro, with compounded drugs as a fallback, and [Hello Alpha](https://glpwatchdog.org/reviews/hello-alpha) bills brand GLP-1s to your own insurance under a monthly clinician membership. [JRNYS](https://glpwatchdog.org/reviews/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](https://glpwatchdog.org/reviews/flytehealth) offers physician-led care that prescribes a GLP-1 only when it fits.

In six states, [TeleSlim Clinic](https://glpwatchdog.org/reviews/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](https://glpwatchdog.org/reviews/rxion-health), [WePeptideRx](https://glpwatchdog.org/reviews/wepeptiderx) and [AlyveRx](https://glpwatchdog.org/reviews/alyverx) list brand Wegovy beside compounded semaglutide; AlyveRx also sells the compounded drug as sublingual drops and does not use insurance. [Nucific](https://glpwatchdog.org/reviews/nucific) lists brand Zepbound and Ozempic next to its compounded and microdosed versions.

## Common questions

## Frequently asked questions

### How long does prior authorization take?

For a commercial or marketplace plan, the insurer must decide a prior authorization within 15 days, or within 72 hours for urgent care. If it is denied and you appeal, they have 30 days to decide that appeal when you have not yet received the drug.

### What is the deadline to file an appeal after a denial?

180 days (six months) from the date you receive the denial notice, for an internal appeal. If that is denied too, you then have 4 months from the final denial to request an independent external review. Both clocks run from when you receive the notice.

### What happens if my internal appeal is denied?

You can take it to external review, where an independent body outside your insurance company decides. Standard external reviews are decided no later than 45 days, expedited ones no later than 72 hours. Your insurer is required to comply with the outcome.

### Can my doctor appeal for me?

Yes. You may appoint a representative to file an external review on your behalf, and healthcare.gov specifically names your doctor or another medical professional who knows your condition as an example. That is usually the person best placed to make the clinical argument.

### Why was my Zepbound or Wegovy prior authorization denied?

The written notice has to state the reason, and it generally comes down to one of four: documentation was missing, a specific criterion was not met, step therapy was required first, or the drug class is excluded from your plan entirely. The first three are answerable with evidence. An exclusion is a contract term, not a clinical judgment, and appealing it as a medical dispute is usually the wrong move.

### What are the prior authorization criteria for Wegovy?

They vary by plan and by employer group within the same insurer, which is why criteria published as a fixed list are often wrong for the person reading them. Plans generally draw on a BMI threshold, a qualifying condition, documented lifestyle efforts, step therapy, and a prescriber attestation. Ask your plan for its written criteria, which are usually published as a coverage policy, and build the request against that document rather than a general one.

### Does any of this apply to compounded GLP-1s?

No. Prior authorization is a process for a drug your plan might cover, and plans do not cover compounded preparations, which is why the compounded market is a cash market. These deadlines are about getting the approved product paid for.

## References

1. Centers for Medicare & Medicaid Services Internal appeals — denial notice deadlines, the 180-day filing window, and 30/60-day decision requirements. HealthCare.gov. 2026. https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/
2. Centers for Medicare & Medicaid Services External review — the 4-month filing window, 45-day and 72-hour decision limits, and appointing a representative. HealthCare.gov. 2026. https://www.healthcare.gov/appeal-insurance-company-decision/external-review/
3. Centers for Medicare & Medicaid Services Weight loss drugs — Medicare GLP-1 Bridge clinical criteria. Medicare.gov. 2026. https://www.medicare.gov/coverage/weight-loss-drugs
4. Biniek JF, Sroczynski N, Freed M, Neuman T. Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024. KFF, January 28, 2026. 2026. https://www.kff.org/medicare/medicare-advantage-insurers-made-nearly-53-million-prior-authorization-determinations-in-2024/
5. Long M, Lo J, Pestaina K. Claims Denials and Appeals in ACA Marketplace Plans in 2024. KFF, March 24, 2026. 2026. https://www.kff.org/patient-consumer-protections/claims-denials-and-appeals-in-aca-marketplace-plans-in-2024/

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Cite as: GLP Watchdog, Nora Bissett, "GLP-1 Prior Authorization: the Criteria, the Clock, the Appeal", published 2026-08-16, updated 2026-10-30. https://glpwatchdog.org/research/glp1-prior-authorization-and-appeals

Canonical HTML page: https://glpwatchdog.org/research/glp1-prior-authorization-and-appeals

Medical disclaimer: Nothing here is medical advice. We report on this subject; we do not treat anyone. Whether to begin a medication, supplement, or treatment, whether to adjust it, and whether to stop are questions for a clinician licensed to answer them, who knows your history.