Find your PBM. Find your PA letter.
Your health plan adjudicates eligibility. Your PBM (pharmacy benefit manager) adjudicates the prior authorization for the drug. Most US health plans contract out PBM duties to one of five entities. Knowing your PBM is often more useful than knowing your plan when you are running a GLP-1 prior auth.
Why the PBM matters more than the plan
Your health plan decides whether you are eligible and what you owe. Your PBM decides whether the drug is approved. For prior authorization on Wegovy, Zepbound, Ozempic or Mounjaro, the PBM is the entity that reads the letter, applies the criteria and issues the approval or denial. The same drug may be approved under Aetna (Caremark PBM) and denied under Cigna (Express Scripts PBM) for the identical clinical picture, because the two PBMs apply different criteria.
Knowing your PBM also tells you the submission portal, the typical turnaround, and the reauthorization pattern. The PBM hubs link out to the existing plan-by-condition templates, with PBM-specific overlay notes added so the letter is tuned to the actual reviewer.
Plan does not match? Try the closest neighbor
Smaller or regional plans (Independence Blue Cross, Premera, Highmark, Geisinger, Healthfirst, GHI, Oscar, Bright HealthCare, Friday Health) are not in our top-10 list, but most of them contract with one of the five PBMs above. Find your PBM on the back of your card and use the closest large-plan template as a starting point. The PA criteria differ at the plan-affiliate margin; the core rationale and the evidence cited do not.
