What is prior authorization?

The plan's permission slip. For a GLP-1 almost every program requires one: the prescriber sends documentation showing the criteria are met, and the pharmacy cannot fill until it is approved. It is not a clinical judgment about whether you need the drug; it is a check that specific boxes have specific evidence behind them.

Why do most requests get refused the first time?

Because a box was empty rather than because the patient was unsuitable. The recurring ones are a BMI documented today when the criteria ask for the baseline before treatment, no attestation about a nutrition and activity program, no record of what was tried first, and an indication written as 'weight loss' on a form for a patient who also has sleep apnea or cardiovascular disease. All four are fixed before submitting, not after.

Should my prescriber write this, or should I?

They submit it; you can hand them the pack. The checklist is what the state asks for, and the covering note is drafted for a clinician to adapt and sign. Nothing in it makes a clinical claim on their behalf.

What if it is refused anyway?

Then the denial names a criterion, and that is the document an appeal is built from. The appeal tool writes that letter, quoting the same state criteria and the federal fair-hearing rules.

Does anything I type get sent to you?

No. Everything is assembled in your browser. There is no account, no upload and no server call on this page.

← Medicaid coverage by state

Prior authorization, before the denial

Most GLP-1 refusals are procedural: a box was empty, not a patient unsuitable. This builds the documentation checklist from your state's own criteria — halfrx has read 48 of the 51 programs' own documents — and drafts a covering note for your prescriber to sign.

Your state

Medication

What is it being prescribed for?

This choice changes the request more than anything else on the form: a diagnosis other than obesity takes the prescription outside the weight-loss exclusion entirely.

Patient name

Member ID

Current BMI

Patient is under 21

Weight-related conditions

Already tried

Nothing typed here is sent anywhere. The pack is assembled in your browser.

What has to be in the submission

BMI documented against what the state publishes on it: 18 and over: a BMI over 30, or over 27 with a weight-related comorbidity such as hypertension, dyslipidemia, diabetes, coronary heart disease, MASH/NASH or sleep apnea — documented in chart notes, not asserted. Under 18: at or above the 95th percentile for age and sex. Wegovy and Saxenda start at 12, Zepbound at 18.— your state's own criteria
Wegovy and Zepbound are preferred and need prior authorization. Saxenda and generic liraglutide are non-preferred: both need trial and failure of two preferred agents, and liraglutide additionally needs a clinically valid reason why brand Saxenda cannot be used. The prescriber must attest the patient is in a nutrition and lifestyle program, no other obesity drug may run alongside it, no second GLP-1 and no DPP-4 inhibitor, and a personal or immediate family history of medullary thyroid carcinoma or MEN2 rules it out.— your state's own criteria
For renewal later: Renewal requires chart notes documenting a loss of at least 5% of baseline body weight — of baseline BMI-for-age under 18 — and continued participation in the lifestyle program. Someone who misses that can be approved for one more month to titrate off.— your state's own criteria
Confirm no personal or family history of medullary thyroid carcinoma or MEN 2, and no history of pancreatitis. Every published GLP-1 criteria set asks, and a blank answer is treated as a fail.— the FDA label
Attest that the patient is in a nutrition and physical-activity program. Most states require the words; some require the program to be named.— your state's own criteria

Covering note for the prescriber

Written to be signed by a clinician, not by you.

[Prescriber name, NPI, practice address]

Re: Prior authorization request — Wegovy
Patient: [patient name], member ID [ID]
Plan: Tennessee Medicaid

To the pharmacy prior-authorization department,

I am requesting Wegovy for chronic weight management.

Current BMI: [value], documented in the chart notes enclosed. Weight-related comorbidities: [list, with diagnosis dates].

This request is submitted against Tennessee Medicaid's published criteria, summarized here: 18 and over: a BMI over 30, or over 27 with a weight-related comorbidity such as hypertension, dyslipidemia, diabetes, coronary heart disease, MASH/NASH or sleep apnea — documented in chart notes, not asserted. Under 18: at or above the 95th percentile for age and sex. Wegovy and Saxenda start at 12, Zepbound at 18. Wegovy and Zepbound are preferred and need prior authorization. Saxenda and generic liraglutide are non-preferred: both need trial and failure of two preferred agents, and liraglutide additionally needs a clinically valid reason why brand Saxenda cannot be used. The prescriber must attest the patient is in a nutrition and lifestyle program, no other obesity drug may run alongside it, no second GLP-1 and no DPP-4 inhibitor, and a personal or immediate family history of medullary thyroid carcinoma or MEN2 rules it out.

Enclosed: chart notes with the baseline and current values, the diagnosis list with dates, and the documentation of the nutrition and activity program the patient is enrolled in.

If any criterion is unmet, please state which one in writing so it can be addressed directly.

[Prescriber signature]
[Date]

Criteria referenced: Clinical Criteria, Step Therapy, and Quantity Limits for the TennCare PDL — https://contenthub-aem.optumrx.com/content/dam/contenthub/onboarding/assets/Tenncare/Criteria-PDL.pdf

Already refused? The appeal letter tool writes the next document, quoting the same criteria plus the federal appeal deadlines and the rule that keeps benefits running if you file within 10 days.

The codes it is written in

A plan checks its criteria against two codes, not one: the obesity code that records the condition and the Z68 code that records the measured BMI. A request refused for “BMI not documented” on a chart where the weight is plainly written is usually missing the second. Every code, quoted from the CMS list, with the label indications the weight-loss exclusion does not reach.

One drug at a time

What each label lets a request claim, what renewal asks, and how long each plan type has to answer.

Zepbound prior authorization →Wegovy prior authorization →Ozempic prior authorization →Mounjaro prior authorization →

What your own plan publishes

An appeal is judged against the criteria the plan wrote, not against a general rule. Each of these sets out what that payer asks for, which document settles it, and where its published policy is.

Medicare →UnitedHealthcare →Blue Cross Blue Shield →Kaiser Permanente →Aetna →Cigna →Humana →TRICARE →VA health care →

Which approval a weight-loss exclusion cannot reach — a plan that excludes obesity treatment may still cover the same drug under its cardiovascular or sleep-apnea indication.

The criteria this fills from

Read from each program's own published document, with the date on it. The other 29 programs are on the coverage page with what is known about each.

Questions

What is prior authorization?: The plan's permission slip. For a GLP-1 almost every program requires one: the prescriber sends documentation showing the criteria are met, and the pharmacy cannot fill until it is approved. It is not a clinical judgment about whether you need the drug; it is a check that specific boxes have specific evidence behind them.
Why do most requests get refused the first time?: Because a box was empty rather than because the patient was unsuitable. The recurring ones are a BMI documented today when the criteria ask for the baseline before treatment, no attestation about a nutrition and activity program, no record of what was tried first, and an indication written as 'weight loss' on a form for a patient who also has sleep apnea or cardiovascular disease. All four are fixed before submitting, not after.
Should my prescriber write this, or should I?: They submit it; you can hand them the pack. The checklist is what the state asks for, and the covering note is drafted for a clinician to adapt and sign. Nothing in it makes a clinical claim on their behalf.
What if it is refused anyway?: Then the denial names a criterion, and that is the document an appeal is built from. The appeal tool writes that letter, quoting the same state criteria and the federal fair-hearing rules.
Does anything I type get sent to you?: No. Everything is assembled in your browser. There is no account, no upload and no server call on this page.

Information only, not medical or legal advice. Criteria are quoted from each program's own published document and dated on the coverage page; where halfrx has not read a state's document, the pack says so instead of guessing.