Prior authorization letter templates for GLP-1.
20 plans × 10 qualifying conditions = 200 ready-to-edit letter templates. Each one cites the plan's current PA policy document, the qualifying ICD-10 codes, the registration-trial evidence and the criteria checklist your clinician needs to fill in. Designed to be copied into your clinician's portal, edited with patient-specific findings and signed. Free. No email gate. No paywall.
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.
Already denied? Go to the appeal letter library → · New to PA? Read the step-by-step PA guide
[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.
The 10 qualifying indications
These are the FDA-approved or evidence-supported indications under which a plan will most defensibly approve a GLP-1. 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.
- Aetna · Commercial / Medicare Advantage · 5-7 business days, 72 hours for urgent
- Cigna · Commercial / Medicare Advantage · 72 hours standard, 24 hours expedited
- UnitedHealthcare · Commercial / Medicare Advantage / Tricare contractor in some regions · 5 business days standard, 72 hours expedited
- Anthem Blue Cross Blue Shield · Commercial / Medicare Advantage / FEP · 5 business days standard
- Blue Shield of California · Commercial / Medicare Advantage · 5 business days
- Kaiser Permanente · Commercial / Medicare Advantage (closed-network HMO) · Internal formulary committee review, varies by region
- Humana · Commercial / Medicare Advantage / Medicare Part D · 72 hours standard, 24 hours expedited
- Tricare · Military 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 benefit · 5 business days standard, 72 hours expedited
- Medicare Advantage (generic letter) · Medicare Advantage Part C with embedded Part D · 72 hours standard, 24 hours expedited
- Independence Blue Cross · Commercial / Medicare Advantage (Greater Philadelphia, southeastern Pennsylvania, southern New Jersey, Delaware) · 5 business days standard, 72 hours expedited
- Highmark Blue Cross Blue Shield · Commercial / Medicare Advantage (Pennsylvania, West Virginia, Delaware, New York) · 5 business days standard, 72 hours expedited
- CareFirst BlueCross BlueShield · Commercial / Medicare Advantage (Maryland, Washington DC, Northern Virginia) · 5 business days standard, 72 hours expedited
- Premera Blue Cross · Commercial / Medicare Advantage (Washington, Alaska) · 5 business days standard, 72 hours expedited
- Florida Blue · Commercial / Medicare Advantage / ACA marketplace (Florida) · 5 business days standard, 72 hours expedited
- Horizon Blue Cross Blue Shield of New Jersey · Commercial / 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 Healthcare · Medicaid 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 Health · Commercial / 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. 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.
