GLP-1 Prior Authorization Letter Generator

Prior authorization, and why a GLP-1 sets one off

Prior authorization (PA) is a utilization management rule insurers use to control spending on high-cost drugs. For brand GLP-1 weight-loss medications — Wegovy, Zepbound, Saxenda, and the newly approved Foundayo — virtually every US commercial plan requires PA before paying any portion of the prescription. The reason is simple: list prices are $649 to $1,349 per month, and a covered patient on therapy for a year represents $7,800 to $16,000 of annual plan spend.

A complete PA submission has to demonstrate three things: (1) the patient meets the FDA-label eligibility criteria (BMI ≥ 30 kg/m², or BMI ≥ 27 kg/m² with at least one weight-related comorbidity), (2) prior weight management attempts have been documented to satisfy the plan's step-therapy requirement, and (3) the prescribing clinician attests to the clinical rationale and ongoing monitoring plan. The letter generated by this tool covers all three and uses FDA-label language verbatim where possible.

How to use the generator

1. Pick your insurer from the dropdown.
2. Choose whichever drug and dose your clinician prescribed.
3. Enter your weight and height — BMI auto-computes.
4. Check off any documented comorbidities.
5. Check off documented prior weight loss attempts (the step-therapy requirement most plans enforce).
6. Copy the letter and bring it to your prescribing clinician. They will review, edit, sign, and submit it through the insurer's pharmacy benefit portal.

Your browser assembles the letter and nothing leaves it: what you type is neither transmitted nor stored, and no patient information is logged.

Sample PA letter (Wegovy + BMI 32 + Type 2 diabetes + Aetna)

A worked example. The case that arises most often is an Aetna-covered patient at BMI 32, documented Type 2 diabetes, requesting Wegovy 2.4 mg. Every combination of drug, insurer and comorbidity is handled by the live generator above.

September 30, 2026

Aetna Pharmacy Prior Authorization Department
Re: Prior Authorization Request

Patient: [Patient Name]
Date of Birth: [MM/DD/YYYY]
Height: 5 ft 8 in
Current Weight: 210 lbs
BMI: 32.0 kg/m²
Requested Medication: Wegovy (semaglutide) 2.4 mg subcutaneous once weekly
Requested Quantity: four (4) single-dose 2.4 mg pens per 28 days

To Whom It May Concern,

This is a request for prior authorization coverage of Wegovy (semaglutide) 2.4 mg subcutaneous once weekly, on behalf of the patient named above, for chronic weight management — an FDA-approved indication.

FDA-Approved Indication. FDA approval for Wegovy (semaglutide) covers chronic weight management in adults, alongside increased physical activity and a reduced-calorie diet, at an initial BMI ≥ 30 kg/m² for obesity — or at BMI ≥ 27 kg/m² for overweight where at least one weight-related comorbid condition is present. Wegovy is additionally FDA-approved (i) to reduce the risk of major adverse cardiovascular events (cardiovascular death, nonfatal myocardial infarction, nonfatal stroke) in adults with established cardiovascular disease and either obesity or overweight (SELECT trial, FDA-approved March 2024), and (ii) for the treatment of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH) with moderate-to-advanced liver fibrosis (stage F2-F3) in conjunction with diet and physical activity (ESSENCE trial, FDA accelerated approval August 2025). If the patient's primary qualifying condition is established CVD or biopsy/imaging-confirmed MASH with fibrosis, submit under that indication.

Patient Eligibility. At a documented 32.0 kg/m², this patient's BMI satisfies the FDA-label obesity criterion of BMI ≥ 30 kg/m². Documented alongside that, this patient carries the following weight-related comorbid condition(s): Type 2 diabetes mellitus (ICD-10 E11.9).

Clinical Rationale. Level 1 evidence out of the STEP-1 pivotal trial supports Wegovy. STEP-1 (Wilding et al., NEJM 2021) demonstrated mean total body weight loss of 14.9% over 68 weeks at the 2.4 mg maintenance dose. Read together, this patient's BMI and their documented comorbid burden put them squarely inside the FDA-approved population that trial studied, and what is requested here is the labeled maintenance dose.

Step Therapy and Prior Treatment History. Ahead of this request the patient has on record the weight management attempts listed below, not one of which produced weight loss that was either sustained or clinically meaningful: supervised reduced-calorie dietary intervention of at least 6 months duration, structured physical activity program of at least 150 minutes per week sustained for 6 months, and prior trial of phentermine, discontinued for inadequate response or intolerance. These attempts satisfy the step-therapy documentation requirement.

Plan-Specific Note. This patient clears the BMI threshold and has documented prior attempts at weight management — the two things step-therapy compliance turns on under the published Aetna Clinical Policy Bulletin covering anti-obesity medications.

Attestation. Coverage criteria as documented by the plan are satisfied here, and so is the indication FDA approval covers. This patient was evaluated by me personally, and everything set out above is accurate so far as I know it. Weight, vital signs and adverse effects will go on being monitored per standard of care. The FDA label sets a discontinuation criterion and I will follow it: therapy stops if total body weight loss of 5% or better has not followed an adequate trial at the maintenance dose.

Requested Action. Approve Wegovy 2.4 mg subcutaneous once weekly for an initial 6-month supply, reauthorization thereafter to turn on documented weight-loss response.

With thanks for reviewing this promptly. Any questions, or any further documentation required, please reach my office.

Sincerely,

[Prescribing Clinician Name, MD]
Prescribing Clinician
_________________________________
Signature                                    Date

DRAFT — the prescribing clinician must review and sign this before it is submitted. Not legal or medical advice.

Frequently asked questions

What is prior authorization for GLP-1 drugs?

A coverage rule, in short. No plan pays for a brand GLP-1 like Zepbound or Wegovy until your doctor has put clinical documentation in front of the insurer — and nothing else obstructs a brand GLP-1 weight-loss approval as much.

Why is prior auth required for Zepbound and Wegovy?

At list price a brand GLP-1 runs $1,000 to $1,400 a month, and PA is how the insurer satisfies itself on three points before paying: that the FDA label criteria are met, that cheaper weight management came first, and that a clinical rationale is documented. See our GLP-1 insurance coverage audit for how coverage rates actually fall out plan by plan.

How long does prior authorization take?

Most commercial plans process a complete PA submission within 3 to 14 business days. Standard turnaround is about 5 business days; expedited reviews are typically 24 to 72 hours. Incomplete submissions add 1 to 2 weeks of back-and-forth — which is exactly the friction this tool is designed to eliminate.

Does my doctor have to write the PA letter?

Yes — the prescribing clinician is required to author and sign the PA letter; insurers will not accept a letter from the patient. This generator produces a draft template the clinician can review, edit, and sign. See our guide on how to get a GLP-1 prescription.

What if my prior auth is denied?

Appeal — the Affordable Care Act protects that right federally. Denials tend to come down to non-formulary status, no documented prior weight-loss attempts, or missing BMI documentation. Ask for a peer-to-peer review, your doctor to the insurance medical director; roughly 30 to 50 percent of first denials fall to it.

Does compounded GLP-1 need prior auth?

No. Out of a 503A or 503B compounding pharmacy, compounded tirzepatide and semaglutide are paid for out of pocket and never reach your insurance pharmacy benefit, so no PA arises. You forgo insurance coverage for that, and pick up quality and supply risk.

Can I appeal a denial?

Yes — an internal appeal goes to the insurer first, and if it is refused again, an independent external review follows. Federal law allows 180 days from the denial notice for that internal filing. Send the original PA letter along with it, plus further clinical documentation; the case is stronger for both.

How is the BMI requirement enforced?

Insurers verify BMI from the height and weight documented in the most recent clinical visit note. The BMI must be calculated and recorded in the patient's chart before PA submission, not estimated. Wegovy, Zepbound, Saxenda, and Foundayo all share the same FDA-label threshold: BMI ≥ 30 kg/m², or BMI ≥ 27 kg/m² with a weight-related comorbidity.

Important disclaimer

What this produces is a draft template, nothing further — not legal advice, not medical advice, and no guarantee that any insurer will cover anything. Nothing goes to an insurer until the prescribing clinician has read, edited and signed it. Where the FDA label supplies wording, that wording is reproduced exactly; where it does not, no clinical recommendation gets invented to fill the gap. GLP Watchdog does not provide medical advice, diagnosis, or treatment recommendations and is not affiliated with any insurer or drug manufacturer.

Related tools and research

• GLP-1 insurance coverage: Medicare, Medicaid, and commercial — what each plan type actually covers
• GLP-1 insurance coverage audit — coverage rates by major commercial plan
• Employer insurance checker — check whether your employer covers GLP-1s
• How to get a GLP-1 prescription — the full clinician workflow
• GLP-1 cost per pound lost calculator — the real cost per pound, list price against covered