Prior authorization checklist: what payers typically require for a GLP-1

Prior authorization is a payer's requirement that a prescriber get approval before a drug is covered. For GLP-1 weight-management drugs it is close to universal where coverage exists at all. The requests that succeed are the complete ones. This checklist is the completeness check, built from three kinds of source: a manufacturer's guide to what payers ask for, a published payer policy, and the AMA's survey of how the process actually behaves.

What payers typically require

Lilly's 2025 prior authorization resource guide for Zepbound, written for prescribers' offices, lists the clinical documentation payers commonly require: a diagnosis of obesity, or overweight with at least one weight-related comorbidity; documented BMI of 30 or higher, or 27 to under 30 with a comorbidity; documentation of the comorbidities themselves, with the note that the qualifying list varies between formularies; weight and BMI; trial, failure or current use of other obesity therapies; and any weight-loss attempts in the past 3, 6 or 12 months, including whether the patient is in a payer, employer or self-started lifestyle programme. For renewals, the guide says to document the percentage of weight lost from baseline and how long the patient has been on a stable dose.

That matches how published payer policies are written. Aetna's Clinical Policy Bulletin 0039 on weight reduction, for example, restates the label population (BMI 30 or higher, or 27 or higher with a comorbidity such as hypertension, type 2 diabetes or dyslipidaemia) and, for liraglutide, a continuation rule taken from that drug's label: stop if at least 4 percent of baseline weight has not been lost after 16 weeks. Your plan's document will have its own version of both halves, the entry criteria and the continuation criteria. Get it before the request goes in.

Why completeness matters

The AMA surveys 1,000 practising physicians on prior authorization every year. In the 2025 survey, 95 percent reported that PA delays access to necessary care at least sometimes, 79 percent that it can lead patients to abandon treatment, and 26 percent that it had led to a serious adverse event for a patient in their care; practices reported completing an average of 40 prior authorizations per physician per week and spending about 13 hours a week on them. An office handling forty of these a week will not chase your missing weight history. Bring it.

Using the sheet

The first block confirms plan facts: whether the drug is on the formulary for weight management at all (an exclusion is a different problem from a denial), whether you have the plan's criteria document, and who submits. The second block is the clinical documentation. Your weight and waist tracker supplies dated weights; the chart supplies BMI and diagnoses; you supply the history of programmes and medications tried, with dates.

The third block is for a denial. HealthCare.gov describes a 180-day window from the denial notice to file an internal appeal, and decision limits of 30 days for a service not yet received, 60 days for one already received, and within 4 business days for urgent cases. The insurance appeal letter template is the next sheet if you get there.

What this sheet does not do

It does not tell you whether you qualify. Only the plan's criteria and your prescriber's documentation answer that. And it is written for a brand-name request; compounded GLP-1s are not FDA approved and are generally not covered through this route at all, which is one reason their cash prices are what the FormBlends cost report compares.