Molina Healthcare prior authorization letter for Type 2 diabetes.
A defensible, plan-specific letter template for Ozempic (semaglutide) or Mounjaro (tirzepatide). T2D is the most defensible PA path. ADA Standards of Care list GLP-1 RA as a preferred second-line agent with documented cardiovascular and renal benefit.
Plan note: Molina Healthcare administers Medicaid managed care in multiple states. Coverage for GLP-1 in obesity follows each state Medicaid PDL, which varies widely (some states cover, most exclude pure obesity indication). T2D pathway is covered nationally with documented A1c and step therapy. Medicare Advantage lines follow CMS rules. CVS Caremark is the PBM for most Molina lines. Verify your specific state Medicaid PDL before submitting an obesity-indication PA.
Molina Healthcare contracts pharmacy benefit administration to CVS Caremark, which adjudicates this PA. The criteria below are pulled from the publicly posted PBM clinical policy. Match each item before you send.
- BMI greater than or equal to 30, OR BMI greater than or equal to 27 with at least one weight-related comorbidity (T2D, hypertension, dyslipidemia, OSA)
- Documented six-month lifestyle intervention or prior anti-obesity medication trial
- Step therapy through phentermine or orlistat (or documented contraindication / intolerance)
- Treatment plan including continued lifestyle counseling and 5 percent weight-loss target at 6 months
- Reauthorization requires documented adherence and ≥5 percent weight loss from baseline at 12 months
Full CVS Caremarkrouting & portal details → · Source: CVS Caremarkclinical policy → (verified May 25)
The letter (copy and edit)
Copy the body below and paste it into your clinician's portal or word processor. Replace every [BRACKET] placeholder with patient-specific data before sending. The letter is from your clinician to the plan, signed by your clinician.
[Today's date] Molina Healthcare Prior Authorization Department Submitted via: Molina provider portal, CoverMyMeds or fax 1-866-449-6843 Re: Prior Authorization Request, Ozempic (semaglutide) or Mounjaro (tirzepatide) Patient: [Patient full name] Member ID: [Plan member ID] Date of birth: [Patient DOB] Group number: [Group number if applicable] Prescriber: [Prescriber full name, NPI, DEA] Prescriber contact: [Phone, fax, email] To the Molina Healthcare Prior Authorization Reviewer, I am the treating clinician for [Patient name]. I am writing to request prior authorization for Ozempic (semaglutide) or Mounjaro (tirzepatide) for treatment of Type 2 diabetes (ICD-10: E11.9, E11.65). Clinical justification Per the American Diabetes Association 2026 Standards of Medical Care in Diabetes, GLP-1 receptor agonists are recommended as a preferred second-line therapy for patients with T2D and established atherosclerotic cardiovascular disease, heart failure or chronic kidney disease, independent of A1c. For patients without these comorbidities, GLP-1 RA is recommended when glycemic control is inadequate on metformin and the patient has a compelling indication for weight loss. The SUSTAIN trial program (semaglutide) and the SURPASS trial program (tirzepatide) demonstrated A1c reductions of 1.5 to 2.5 percentage points with weight loss of 5 to 15 percent at maximally tolerated doses. Patient-specific findings - [Insert current measurements: weight, height, BMI, blood pressure] - [Insert relevant lab values with dates: A1c, lipid panel, kidney function] - [Insert documentation of comorbidities with ICD-10] - [Insert documentation of prior treatment history, including any prior GLP-1 trials, anti-obesity medication trials or lifestyle intervention] Criteria met per Molina Healthcare policy This request meets the criteria set out in Molina Clinical Policy, GLP-1 Receptor Agonists: - Diagnosis of T2D documented with ICD-10 E11.x - Current A1c, with date drawn (most plans want a result within the past 90 days) - Failure of or contraindication to metformin (or current metformin use that is no longer adequate) - Documented lifestyle intervention (medical nutrition therapy or diabetes self-management education) - Treatment goals (target A1c, target weight if relevant) Supporting evidence The clinical case for Ozempic (semaglutide) or Mounjaro (tirzepatide) in this indication is supported by the following registration trials and outcomes data: - SUSTAIN-6 (semaglutide cardiovascular outcomes in T2D) - REWIND (dulaglutide cardiovascular outcomes in T2D) - SURPASS-1 through SURPASS-5 (tirzepatide glycemic and weight outcomes) Plan-specific note Molina Healthcare administers Medicaid managed care in multiple states. Coverage for GLP-1 in obesity follows each state Medicaid PDL, which varies widely (some states cover, most exclude pure obesity indication). T2D pathway is covered nationally with documented A1c and step therapy. Medicare Advantage lines follow CMS rules. CVS Caremark is the PBM for most Molina lines. Verify your specific state Medicaid PDL before submitting an obesity-indication PA. Requested action I am requesting prior authorization for Ozempic (semaglutide) or Mounjaro (tirzepatide) at the [insert starting dose] starting dose, with planned titration per FDA labeling. I am also requesting that this authorization be granted for a continuous 12-month period subject to documented clinical response, per standard formulary practice. If additional information is required, please contact me directly at [Prescriber phone] or [Prescriber email]. I am available to discuss this case with your medical director if helpful. Thank you for your attention to this request. Sincerely, [Prescriber full signature] [Prescriber printed name, credentials] [Prescriber NPI] [Practice name and address] Attachments: - Current vital signs and BMI calculation - Most recent relevant labs - Documentation of comorbidities - Documentation of prior treatment trials - Sleep study report (if OSA indication) - Cardiac history documentation (if CV indication)
Clinical rationale for this indication
Per the American Diabetes Association 2026 Standards of Medical Care in Diabetes, GLP-1 receptor agonists are recommended as a preferred second-line therapy for patients with T2D and established atherosclerotic cardiovascular disease, heart failure or chronic kidney disease, independent of A1c. For patients without these comorbidities, GLP-1 RA is recommended when glycemic control is inadequate on metformin and the patient has a compelling indication for weight loss. The SUSTAIN trial program (semaglutide) and the SURPASS trial program (tirzepatide) demonstrated A1c reductions of 1.5 to 2.5 percentage points with weight loss of 5 to 15 percent at maximally tolerated doses.
ICD-10 codes to attach
E11.9E11.65
Criteria checklist (what to attach with the letter)
- Diagnosis of T2D documented with ICD-10 E11.x
- Current A1c, with date drawn (most plans want a result within the past 90 days)
- Failure of or contraindication to metformin (or current metformin use that is no longer adequate)
- Documented lifestyle intervention (medical nutrition therapy or diabetes self-management education)
- Treatment goals (target A1c, target weight if relevant)
Supporting trials and evidence
- SUSTAIN-6 (semaglutide cardiovascular outcomes in T2D)
- REWIND (dulaglutide cardiovascular outcomes in T2D)
- SURPASS-1 through SURPASS-5 (tirzepatide glycemic and weight outcomes)
The denial reasons to preempt
Most denials of this combination cite one of the reasons below. Address each one in the patient-specific findings section before you send. If the plan denies anyway, the appeal letter cites the same evidence with the denial reason added in the opening paragraph.
- A1c on file is older than 90 days
- No documentation of metformin trial or contraindication
- Prior auth submitted for Wegovy or Zepbound (which are obesity-indication brands) rather than Ozempic or Mounjaro (the T2D-indication brands of the same molecule)
If you have not picked a program yet
The PA path is faster when your prescriber is already familiar with your insurance plan and runs the authorization regularly. Programs in our chart that actively run prior authorization for Ozempic:
- PlushCare · commercial and Medicare PA experience
- Form Health · obesity-medicine specialty, high PA success rate
- Knownwell · cardiometabolic focus, all major PBMs
- Calibrate · insurance-focused, employer-friendly
Other indications under Molina Healthcare
If this indication is not the right fit, try a different qualifying indication under the same plan:
Same indication, other plans
Same Type 2 diabetes indication, different plan-specific letter templates if your insurance is not Molina Healthcare:
Disclaimer
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.
