GLP-1 Prior Authorization Checklist: Paperwork to Gather First

A GLP-1 prior authorization usually asks your prescriber to show why the medicine is being prescribed and that you meet the plan's criteria. That typically means the diagnosis, a dated BMI (height and weight), any weight-related health conditions, what you've already tried, a lifestyle or nutrition plan, and a check that nothing on the drug label rules you out. Your prescriber submits it. Your job is to make sure the facts are easy to find and that nobody drops the ball between the office, the plan and the pharmacy.

This checklist is for the before and during. If you've already been denied, jump to our appeal organizer.

What is prior authorization for a GLP-1, in plain English?

It's the plan saying: "We'll consider paying, but first show us this person meets our rules." It isn't a judgment about your effort or your body. It's a form-matching exercise, and forms are picky.

The rules belong to your plan. Two plans can both cover Wegovy and ask for different things. So step zero is always the same: get the criteria in writing.

Step 0: Get your plan's criteria

Before anyone fills in a form, ask the plan (member services number on your card, or the member portal) for:

• The prior authorization criteria or coverage policy for your exact drug and form (pen, vial or tablet)
• Whether it's covered for weight management, not just for diabetes
• Whether a lifestyle program or dietitian visit is required (what that means)
• Whether a preferred drug must be tried first (step therapy)
• How long an approval lasts and what renewal requires
• The fax number or electronic portal the prescriber should use

If the plan says the drug is excluded for weight management, prior authorization won't change that for this plan year. Better to know on day one.

What documents do GLP-1 prior authorizations usually ask for?

Criteria vary, but they tend to look like the questions on Medicare's own GLP-1 Bridge prior authorization form, which is a public example: BMI at the start of GLP-1 treatment, specific weight-related conditions, whether the person has type 2 diabetes, and a prescriber attestation that the drug is used alongside diet and activity changes. Commercial plans write their own versions, but expect the same kinds of questions.

What you can gather (patient side):

• Insurance card: member ID, group number, pharmacy BIN/PCN (back of the card)
• Your weight history with dates, especially your weight on the day you started (or will start) a GLP-1
• Height (yes, they need it for BMI)
• List of diagnoses you've been told about, like high blood pressure, prediabetes, sleep apnea, high cholesterol or joint problems
• Current medicines and doses, including any other weight-management or diabetes drugs
• Past weight-management medicines you've tried, with rough dates and why you stopped
• Proof of any lifestyle, nutrition or coaching program, if the plan requires one (enrollment emails, visit summaries)

What your prescriber's office usually supplies:

• Diagnosis codes and chart notes supporting the indication
• Documented BMI and measurement date
• Notes on the qualifying conditions the plan lists
• Confirmation there's no label contraindication. Zepbound's label, for example, says not to use it with a personal or family history of medullary thyroid carcinoma or MEN 2, and doesn't recommend combining it with another GLP-1 medicine
• The completed plan form or electronic submission

Privacy tip: send only what the plan asks for, through the channel it names. A full medical history "just in case" mostly creates more paper for someone to skim past.

Who does what: the handoff map

Most delays happen in the gaps between people. Write the owner next to each step:

Step	Usually done by	Owner (name)	Done?
Send prescription to pharmacy	Prescriber		☐
Pharmacy runs claim, gets "PA required"	Pharmacy		☐
Request PA form from plan	Pharmacy or prescriber		☐
Fill in and submit form	Prescriber's office		☐
Supply weight history, program proof	You → office		☐
Decision sent	Plan → prescriber (and often you)		☐
Pharmacy re-runs claim after approval	Pharmacy		☐

That last step trips people up. An approval doesn't always reach the pharmacy automatically. If you've been told "approved" and the pharmacy still says "rejected," ask them to rerun the claim.

How long does a GLP-1 prior authorization take?

For many job-based and individual plans, HealthCare.gov lists these decision timelines:

• Prior authorization (care not yet received): up to 15 days
• Urgent situations: up to 72 hours

Medicare's GLP-1 Bridge promises decisions within 72 hours of submission. Your plan's own documents will give its exact timelines. If you've passed them, that's a good reason to call.

The status tracker (copy this)

Date	What happened	Who I spoke to	Reference #	Next check-in date
	Pharmacy said PA needed
	Office confirmed submission
	Plan confirmed receipt
	Decision received

A good rhythm: confirm the office submitted (not "will submit"), then confirm the plan received it, then wait out the timeline.

Is there anything I should not do?

• Don't change, stretch or skip doses because paperwork is slow. If a gap in supply is coming, tell your prescriber. Our guide to restarting after a break explains why restart instructions matter.
• Don't overstate anything. Criteria are checked against records, and inaccurate information can cause bigger problems later.
• Don't resubmit everything blindly after a "missing information" notice. Ask the plan exactly which item is missing.

What about renewal?

Approvals often have an end date. When yours is approved, write the expiry date in your calendar about a month early, and ask what renewal requires. Some plans want to see how you've responded to treatment, so a steady record of weight and measurements helps. GLPily logs weight, measurements and your dose history over time, so the numbers are ready when the office asks. See sharing a tracking report with your clinician.

Common questions

Who submits a GLP-1 prior authorization, me or my doctor?

Your prescriber's office submits it. You can speed things up by getting the plan's criteria and handing over dated weight records, medication history and any program proof.

What BMI is needed for GLP-1 prior authorization?

It depends on your plan. As one public example, Medicare's GLP-1 Bridge uses BMI at the start of treatment: 35+, or 30+ or 27+ with specific conditions. Commercial plans set their own cutoffs, so ask yours.

My prior authorization was approved but the pharmacy still can't fill it. Why?

Often the pharmacy needs to rerun the claim after the approval is recorded, or the approval was for a different form or strength than the prescription. Ask the pharmacy to rerun it and compare the drug details.

What if my prior authorization is denied?

Read the denial reason and deadline on the notice, then follow our step-by-step appeal organizer.