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.
What has to be in the submission
- BMI documented against what the state publishes on it: Texas publishes no threshold for obesity itself, because obesity alone is never an approvable reason: the decision tree denies at step two without a cardiovascular diagnosis. The qualifying-diagnosis list at step three does set a floor — Table 3 takes the obesity and overweight codes and the BMI codes from Z68.27, a BMI of 27.0, upwards.— your state's own criteria
- Wegovy is approved only with a cardiovascular-disease diagnosis recorded in the past 730 days alongside a diagnosis of obesity or overweight, no concurrent GLP-1, and no history of pancreatitis, gastroparesis, medullary thyroid carcinoma or MEN 2 in the past 180 days. An approval runs 365 days.— 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: Texas 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 Texas Medicaid's published criteria, summarized here: Texas publishes no threshold for obesity itself, because obesity alone is never an approvable reason: the decision tree denies at step two without a cardiovascular diagnosis. The qualifying-diagnosis list at step three does set a floor — Table 3 takes the obesity and overweight codes and the BMI codes from Z68.27, a BMI of 27.0, upwards. Wegovy is approved only with a cardiovascular-disease diagnosis recorded in the past 730 days alongside a diagnosis of obesity or overweight, no concurrent GLP-1, and no history of pancreatitis, gastroparesis, medullary thyroid carcinoma or MEN 2 in the past 180 days. An approval runs 365 days. 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: Texas Prior Authorization Program Clinical Criteria — Wegovy — https://paxpress-txpa.acentra.com/wegovy.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.
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.
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.