GLP-1 prior authorization letter templates.

A GLP-1 prior authorization (PA) letter template is a pre-written letter your prescriber submits to your insurance plan to request coverage approval for Wegovy, Zepbound, Ozempic or Mounjaro. GLP Chart provides 18 free templates across 13 US health plans and 7 qualifying conditions. Each template cites your plan's current PA policy and the ICD-10 codes a reviewer checks, with [BRACKET] placeholders for patient-specific data. Find your plan and condition below, copy the letter, and take it to your prescriber to sign and submit. PA criteria verified July 13.

These templates are a starting point. They are not a prescription, not a guarantee of coverage, and not medical advice.

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Already denied? Go to the appeal letter library →

Key facts

18 free templates covering 13 US health plans and 7 qualifying conditions. Drugs covered: Wegovy (semaglutide 2.4mg), Zepbound (tirzepatide), Ozempic, and Mounjaro.
What a GLP-1 PA letter template is.A pre-written prior authorization letter your prescriber submits to your insurance plan. Each template cites the plan's specific policy criteria and the ICD-10 diagnosis codes the reviewer checks. [BRACKET] placeholders mark the patient-specific data your clinician fills in.
First-pass denials are common. In ACA marketplace plans, 44 percent of appealed denials were reversed in 2023 (KFF, all categories). A denial is worth fighting with the right letter.
Already denied? Go to the appeal letter library for templates matched to the exact denial reason your plan cited (formulary exclusion, medical necessity, lifestyle documentation).
Medicare patients: the Medicare GLP-1 Bridge is now live (July 1, 2026) at a flat $50/month for Wegovy, Foundayo and the Zepbound pen. PA templates for Medicare Advantage plans are included.

How to use these templates. Find your plan and the indication you qualify under in the list below, then 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 to review, sign, and submit.

All 18 letter templates

One template per plan-and-condition combination, matched to give you the most defensible letter for your specific plan.

WegovyZepboundOzempic

The 7 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 13 plans we cover

We cover the plan-condition combinations people actually search for: national carriers (Humana, Anthem BCBS), the major regional BCBS plans (Blue Shield of California, Highmark, CareFirst, Premera, Florida Blue, FEHB), Medicare Advantage and managed care (Wellcare), the ACA marketplace (Ambetter, Oscar) and the closed-system and military plans (Kaiser Permanente, Tricare). Plan-specific policy citations are pulled from each carrier's most recent published criteria.

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

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

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

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

First-pass GLP-1 PAs are denied often. The appeal success rate is much higher than first-pass approval, because the appeal letter (Level 1 appeal then Level 2 then external review) lets you address the specific denial reason directly. In ACA marketplace plans, 44 percent of appealed denials were reversed in 2023 (KFF, all categories).

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.

While coverage is pending, or if it never comes through, the GLP-1 cost guide shows what every cash-pay path actually costs at maintenance dose, from the $149-a-month compounded floor to manufacturer-direct branded pricing.

GLP-1 prior authorization FAQ

What is a GLP-1 prior authorization letter?

A prior authorization (PA) letter is a document your prescriber submits to your insurance plan requesting approval to cover a GLP-1 medication such as Wegovy or Zepbound. Most commercial plans require one for weight management or cardiovascular indications. A good PA letter cites the plan's specific policy number, your diagnosis code, BMI, qualifying comorbidities, and any required lifestyle documentation. Insurers use the letter to verify you meet clinical criteria before approving the drug.

How long does GLP-1 prior authorization take?

Most insurers process a GLP-1 prior authorization within 3 to 5 business days for a standard review. Urgent requests must be decided within 72 hours. Submit by fax through your prescriber's office for the fastest turnaround; some plans also accept electronic PA submission through the prescriber's EHR. If you have not heard back in 5 business days, your prescriber's office can follow up by phone with the plan's pharmacy PA department using the number on your insurance card.

What happens if my GLP-1 prior authorization is denied?

A first-pass GLP-1 PA denial is common, not final. You have the right to appeal. A Level 1 internal appeal lets you rebut the specific denial reason using the plan's own policy language and your medical records. If that fails, a Level 2 appeal goes to a different reviewer, and an external review by an independent organization is typically available after that. In ACA marketplace plans, 44 percent of appealed denials were reversed in 2023 (KFF). The most common denial reasons for GLP-1s are incomplete lifestyle documentation, missing comorbidity documentation, and step-therapy requirements. See the appeal letter library for templates by denial reason.

Do I need a prior authorization letter for every GLP-1?

Prior authorization is required by most commercial insurance plans for Wegovy, Zepbound, Ozempic, and Mounjaro for the obesity and cardiovascular indications. The diabetes brands (Ozempic, Mounjaro) are less frequently restricted on commercial formularies than the weight-management brands. Medicare Part D requires PA for the cardiovascular and sleep-apnea indications. Medicaid PA requirements vary by state.

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.
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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 every Monday.

GLP-1 prior authorization letter templates.

All 18 letter templates

The 7 qualifying indications

The 13 plans we cover

If you get denied

GLP-1 prior authorization FAQ

What this is and what it is not

New prior-auth templates every Monday.