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

A current BMI in the chart, and the baseline BMI at the start of therapy if treatment has already begun. halfrx has read this state's own document but recorded no BMI threshold from it, so this is the pattern every published program uses rather than a quotation from yours.— federal rule
For the indications Utah still covers: Wegovy for a prior major adverse cardiovascular event needs a BMI of 27 or more with a documented MI, stroke or symptomatic peripheral arterial disease and guideline-directed secondary prevention; Zepbound for sleep apnea needs a BMI of 30 or more, an apnea-hypopnea index of 15 or higher on an attended study, a sleep specialist and 70% adherence to PAP; Wegovy for MASH needs stage F2 to F3 fibrosis confirmed two ways and a liver specialist. All of them require an exercise program and a calorie-restricted diet, no other GLP-1, GIP or DPP-4 agent, and no personal or family history of medullary thyroid carcinoma or MEN 2.— your state's own criteria
For renewal later: Weight-loss reauthorization was open only to somebody whose approval was already active between 1 July 2025 and 30 June 2026, and ran no later than 30 June 2026. On the other indications: Wegovy for cardiovascular risk renews for 12 months on 5% weight loss held from week 20; Zepbound for sleep apnea on a 20% fall in the apnea-hypopnea index; Wegovy for MASH on documented clinical response.— 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: Utah 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 Utah Medicaid's published criteria, summarized here: For the indications Utah still covers: Wegovy for a prior major adverse cardiovascular event needs a BMI of 27 or more with a documented MI, stroke or symptomatic peripheral arterial disease and guideline-directed secondary prevention; Zepbound for sleep apnea needs a BMI of 30 or more, an apnea-hypopnea index of 15 or higher on an attended study, a sleep specialist and 70% adherence to PAP; Wegovy for MASH needs stage F2 to F3 fibrosis confirmed two ways and a liver specialist. All of them require an exercise program and a calorie-restricted diet, no other GLP-1, GIP or DPP-4 agent, and no personal or family history of medullary thyroid carcinoma or MEN 2.

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: Utah Medicaid pharmacy prior authorization request form: GLP-1 medications for weight-related comorbidities, last updated 1 June 2026 (read via the Internet Archive) — https://web.archive.org/web/20260717062448/https://medicaid-documents.dhhs.utah.gov/pharmacy/priorauthorization/pdf/GLP-1+Medications+for+Weight-related+Comorbidities.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.