Independent · Updated June 5 · Not legal or medical advice

Prior authorization letter templates for GLP-1.

Insurance denied your GLP-1? These are ready-to-edit prior-authorization letters your doctor can sign and send. Find your insurer and your condition below, then copy the template that matches. Each one already quotes your plan's current PA policy and the diagnosis codes a reviewer looks for.

These templates are a starting point for your clinician. They are not a prescription, not a guarantee of coverage, and not medical advice. Your clinician signs and submits.

Find my plan and condition ↓Or find me by my PBM →

Already denied? Go to the appeal letter library → · New to PA? Read the step-by-step PA guide

How to use these templates. Find your plan in the row labels, then find the indication you qualify under in the column labels. Click through to your specific combination. Each template is a structured letter body with placeholder tokens in [BRACKETS] where patient-specific data goes. Copy the letter, fill in the brackets and take it to your prescriber for review and signature. The letter is from your clinician to the plan, not from you. Your clinician is the only person who can sign it.

All 200 combinations

Pick your insurance plan on the left and the indication on the right. Templates pair to give you the most defensible letter for your specific plan-and-condition combination.

WegovyZepboundOzempic

Type 2 diabetes

Obesity with one or more comorbidities

Obstructive sleep apnea (Zepbound SURMOUNT-OSA indication)

Cardiovascular risk indication (Wegovy SELECT)

PCOS with metabolic syndrome

Post-bariatric weight regain

Obesity Class III (BMI 40 or higher)

Type 2 diabetes with chronic kidney disease

MASH or NAFLD with obesity

Prediabetes with progression risk

Aetna

Commercial / Medicare Advantage

Cigna

Commercial / Medicare Advantage

UnitedHealthcare

Commercial / Medicare Advantage / Tricare contractor in some regions

Anthem Blue Cross Blue Shield

Commercial / Medicare Advantage / FEP

Blue Shield of California

Commercial / Medicare Advantage

Kaiser Permanente

Commercial / Medicare Advantage (closed-network HMO)

Humana

Commercial / Medicare Advantage / Medicare Part D

Tricare

Military health system (East, West, Overseas, Reserve Select, Young Adult)

FEHB Blue Cross Blue Shield (Federal Employee Program)

Federal employee health benefit

Medicare Advantage (generic letter)

Medicare Advantage Part C with embedded Part D

Independence Blue Cross

Commercial / Medicare Advantage (Greater Philadelphia, southeastern Pennsylvania, southern New Jersey, Delaware)

Highmark Blue Cross Blue Shield

Commercial / Medicare Advantage (Pennsylvania, West Virginia, Delaware, New York)

CareFirst BlueCross BlueShield

Commercial / Medicare Advantage (Maryland, Washington DC, Northern Virginia)

Premera Blue Cross

Commercial / Medicare Advantage (Washington, Alaska)

Florida Blue

Commercial / Medicare Advantage / ACA marketplace (Florida)

Horizon Blue Cross Blue Shield of New Jersey

Commercial / Medicare Advantage / Medicaid managed care (New Jersey)

Wellcare (Centene)

Medicare Advantage / Medicare Part D (national)

Molina Healthcare

Medicaid managed care / Medicare Advantage / ACA marketplace (multi-state)

Ambetter (Centene marketplace)

ACA marketplace / Health Insurance Exchange (multi-state, Centene affiliate)

Oscar Health

Commercial / ACA marketplace (multi-state)

The 10 qualifying indications

These are the FDA-approved or evidence-supported indications under which a plan will most defensibly approve a GLP-1. Each card lists its ICD-10 codes (the diagnosis codes your clinician puts on the prior-auth). The right indication for you depends on your clinical picture. Discuss with your prescriber.

The 20 plans we cover

We cover the largest national carriers (Aetna, Cigna, UnitedHealthcare, Humana, Anthem BCBS), the major regional BCBS plans (Independence, Highmark, CareFirst, Premera, Florida Blue, Horizon, FEHB), the Medicare Advantage and Medicaid managed-care landscape (Wellcare, Molina), the ACA marketplace (Ambetter, Oscar) and the closed-system and federal plans (Kaiser, Tricare). Plan-specific policy citations are pulled from each carrier's most recent published criteria.

AetnaCommercial / Medicare Advantage5-7 business days, 72 hours for urgent

CignaCommercial / Medicare Advantage72 hours standard, 24 hours expedited

UnitedHealthcareCommercial / Medicare Advantage / Tricare contractor in some regions5 business days standard, 72 hours expedited

Anthem Blue Cross Blue ShieldCommercial / Medicare Advantage / FEP5 business days standard

Blue Shield of CaliforniaCommercial / Medicare Advantage5 business days

Kaiser PermanenteCommercial / Medicare Advantage (closed-network HMO)Internal formulary committee review, varies by region

HumanaCommercial / Medicare Advantage / Medicare Part D72 hours standard, 24 hours expedited

TricareMilitary health system (East, West, Overseas, Reserve Select, Young Adult)5 business days standard, 24 hours emergency

FEHB Blue Cross Blue Shield (Federal Employee Program)Federal employee health benefit5 business days standard, 72 hours expedited

Medicare Advantage (generic letter)Medicare Advantage Part C with embedded Part D72 hours standard, 24 hours expedited

Independence Blue CrossCommercial / Medicare Advantage (Greater Philadelphia, southeastern Pennsylvania, southern New Jersey, Delaware)5 business days standard, 72 hours expedited

Highmark Blue Cross Blue ShieldCommercial / Medicare Advantage (Pennsylvania, West Virginia, Delaware, New York)5 business days standard, 72 hours expedited

CareFirst BlueCross BlueShieldCommercial / Medicare Advantage (Maryland, Washington DC, Northern Virginia)5 business days standard, 72 hours expedited

Premera Blue CrossCommercial / Medicare Advantage (Washington, Alaska)5 business days standard, 72 hours expedited

Florida BlueCommercial / Medicare Advantage / ACA marketplace (Florida)5 business days standard, 72 hours expedited

Horizon Blue Cross Blue Shield of New JerseyCommercial / Medicare Advantage / Medicaid managed care (New Jersey)5 business days standard, 72 hours expedited

Wellcare (Centene)Medicare Advantage / Medicare Part D (national)72 hours standard, 24 hours expedited

Molina HealthcareMedicaid managed care / Medicare Advantage / ACA marketplace (multi-state)5 business days standard, 72 hours expedited (Medicaid varies by state)

Ambetter (Centene marketplace)ACA marketplace / Health Insurance Exchange (multi-state, Centene affiliate)5 business days standard, 72 hours expedited

Oscar HealthCommercial / ACA marketplace (multi-state)5 business days standard, 72 hours expedited

If you get denied

Roughly 40 to 60 percent of first-pass GLP-1 PAs are denied. The appeal success rate is much higher than first-pass approval, often 60 to 75 percent, because the appeal letter (Level 1 appeal, then Level 2, then external review) lets you address the specific denial reason directly.

Each template page lists the most common denial triggers for that indication. Read those before you send the first letter so you can preempt them. If your denial cites a reason not in our list, email hello@glpchart.com with the denial letter and we will update the template.

What this is and what it is not

Educational templates only. Not legal or medical advice. Letters must be signed by a treating clinician (MD, DO, NP, PA) with prescribing authority. Each plan changes criteria quarterly. Verify against your plan's most recent PA policy bulletin before sending. Do not fabricate clinical findings. Do not alter a clinician's signature.

John Samaras, Founder and editorI started GLP Chart after overpaying for a GLP-1 myself. Based in Austin, Texas. About this site · LinkedIn · Contact

Why you can trust GLP ChartSame scoring framework applied to every program. No paid placements. We never remove unfavorable information at an advertiser's request. Pricing is pulled from each program's public-facing page weekly.

Prior authorization letter templates for GLP-1.

All 200 combinations

The 10 qualifying indications

The 20 plans we cover

If you get denied

What this is and what it is not

Get every price change