Insurance

GLP-1 prior authorization: criteria, checklist, and how to get approved

Prior authorization is the friction step almost everyone hits. Below: what the big pharmacy benefit managers typically require, a documentation checklist to clear it the first time, the peer-to-peer script, realistic timelines, the ≥5% renewal rule that catches people at month four, and exactly what to do for each denial reason.

Written byGLP1Zoom Editorial, Medical content team · Independent editorial

Medically reviewed byGLP1Zoom Editorial Team, Evidence-based editorial review Reviewed Jun 10, 2026

Verified Jul 2026 · re-checked quarterlyBy the GLP1Zoom editorial teamWe compare, we don’t sell

The short answer

For weight-loss GLP-1s (Wegovy, Zepbound), the typical criteria are: BMI ≥30, or ≥27 with a weight-related condition; a documented ~90-day supervised lifestyle program; sometimes step therapy; and a ≥5% weight-loss rule to renew. Diabetes drugs (Ozempic, Mounjaro) need type-2-diabetes documentation instead. Criteria vary by plan — and a flat weight-loss exclusion is a different problem than a PA denial.

Key takeaways

Common weight-loss GLP-1 PA criteria: BMI ≥30, or ≥27 with a weight-related comorbidity (hypertension, T2D, dyslipidemia, OSA, or CVD).
Documentation of a supervised diet-and-exercise program is usually required — often ~90 days (CVS Caremark specifies ≥90 consecutive days with dietary counseling, not just an attestation).
Re-authorization typically requires documented weight loss of ≥5% from baseline (checked ~4-6 months in) — record your starting weight or the renewal fails.
Step therapy varies: some plans make Wegovy preferred and require a 12-16 week Wegovy trial before approving Zepbound; others require an oral agent first.
Ozempic/Mounjaro (diabetes drugs): PA is about documenting type 2 diabetes (diagnosis + often A1c, sometimes a metformin trial); weight-loss-only use is off-label and typically NOT covered.
Standard PA decisions usually come within a few business days (often ~72 hours); missing documentation is the #1 cause of delay and denial.

How the big PBMs compare

Three pharmacy benefit managers process most US commercial prescriptions. Their weight-loss GLP-1 criteria follow a common pattern with meaningful differences — this is the typical shape, and your specific plan (or employer benefit design) can differ:

Requirement	Typical pattern	Notable variation
BMI threshold	≥30, or ≥27 + comorbidity	Consistent across major PBMs
Lifestyle program	~3 months documented	CVS Caremark: ≥90 consecutive days, supervised
Step therapy	Varies by plan	CVS: Wegovy preferred → 12–16 wk Wegovy trial before Zepbound; Cigna/ESI may require an oral agent first
Renewal rule	≥5% weight loss from baseline	OptumRx documents >5%; checked ~4–6 months in
Quantity limit	One month / one titration pack	Common across plans

Note: many employer plans exclude weight-loss drugs entirely regardless of criteria — check whether yours has the benefit at all before chasing a PA.

The documentation checklist (bring this to your appointment)

Missing documentation is the single biggest cause of denials and delays. Make sure your chart has all of this before the PA is submitted:

Current height, weight, and BMI

Recorded in the chart at the visit — not self-reported in passing.

A qualifying comorbidity (if BMI is 27–30)

Hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, or cardiovascular disease — documented as a diagnosis.

Supervised lifestyle program records

Dates and content of a diet-and-exercise attempt, commonly ~90 days. Real documentation (visits, counseling), not a checkbox.

Baseline weight at initiation

The number your ≥5% renewal will be measured against. If this is missing, your month-4 renewal is at risk.

Step-therapy evidence (if required)

Which drug was tried, for how long, and the outcome — weight loss achieved or documented intolerance.

The ≥5% renewal rule (the month-four trap)

Getting approved isn't the end. At re-authorization (commonly 4–6 months in), most plans require documented weight loss of ≥5% from your baselineto keep covering the drug — mirroring the FDA labels' own reassessment guidance. Two things sink renewals: a missing baseline weight (nothing to measure against), and weights recorded inconsistently (different scales/clothing). Ask your prescriber to record weight the same way at each visit, and confirm the baseline is in the chart on day one.

Timeline: what to expect

Submission: your prescriber sends the PA with documentation.
Standard decision: typically within a few business days (often up to ~72 hours).
Expedited/urgent: faster, when clinically justified.
If denied: peer-to-peer review, then internal appeal, then independent external review — each with its own deadline.

The peer-to-peer: what your prescriber should say

A peer-to-peer is a direct call between your prescriber and the plan's medical reviewer, and it resolves many denials faster than paperwork. An effective one covers, concisely:

The patient's BMI and qualifying comorbidity, with dates.
The documented lifestyle attempt — what was tried and for how long.
Why alternatives are inappropriate or already failed (if step therapy is at issue).
The specific FDA indication being treated — e.g. cardiovascular risk reduction for Wegovy in a patient with established heart disease, or obstructive sleep apnea for Zepbound.
A clear ask: approval under the plan's stated criteria, or the exact documentation still needed.

Denied? Match the fix to the reason

Denial reason	What actually fixes it
Missing documentation	Submit the records (baseline weight, lifestyle program, comorbidity) and resubmit
Doesn't meet BMI criteria	Document a qualifying comorbidity if BMI is 27–30; otherwise reassess eligibility
Step therapy required	Document the required trial and its outcome, or an intolerance
Non-formulary / non-preferred	Request a formulary exception (medical necessity) — not a standard PA
Weight-loss drugs excluded	A PA can't fix a benefit exclusion — pivot to a covered indication, the Medicare Bridge, or cash-pay

Full steps and deadlines: GLP-1 denial appeal and formulary exception. If your plan excludes weight-loss drugs entirely, see the Medicare Bridge (Medicare) or cash-pay options.

Diabetes drugs are a different process

For Ozempic and Mounjaro, prior authorization is about documenting type 2 diabetes — a diagnosis and often A1c values, sometimes a prior metformin trial — not weight-loss criteria. Weight-loss-only use is off-label and typically not covered. Per-drug detail: Wegovy, Zepbound (which also has an easier sleep-apnea path).

These are typical commercial-plan criteria as of 2026-07 and vary by plan and employer benefit design; PBM policies revise quarterly. Always confirm your specific plan's policy. Educational only, not medical or insurance advice.

Providers who handle the prior authorization for you

Common questions about GLP-1 prior authorization

What are the prior authorization criteria for GLP-1 weight-loss drugs?

While every plan is different, the common commercial pattern for Wegovy and Zepbound is: a BMI of 30 or higher, or 27 or higher with a weight-related condition (high blood pressure, type 2 diabetes, high cholesterol, sleep apnea, or heart disease); documentation of a supervised diet-and-exercise program (often about 3 months / 90 days); sometimes step therapy (trying another agent first); and a re-authorization rule requiring you to have lost at least 5% of your body weight to keep the drug covered. Quantity limits also apply. Your specific plan's criteria can differ — check its policy.

What is the 5% weight-loss rule for GLP-1 prior authorization?

Most pharmacy benefit managers (CVS Caremark, Express Scripts, OptumRx) require documented weight loss of at least 5% from your starting weight to renew coverage — typically checked at the first re-authorization, around 4 to 6 months in. This mirrors the FDA labels, which say to reassess and consider stopping if a patient hasn't lost about 5% by that point. Practical tip: make sure your baseline weight is documented at the very start so the loss can be measured against it — a missing baseline is one of the most common reasons renewals get denied.

How long does GLP-1 prior authorization take?

Once your prescriber submits a complete prior-authorization request with the required documentation, plans generally respond within a few business days for a standard request (often up to about 72 hours, faster for urgent/expedited requests). Delays usually come from missing documentation — a missing baseline weight, incomplete lifestyle-program records, or a missing comorbidity diagnosis. Submitting everything the first time is by far the fastest path.

What documentation do I need for a GLP-1 prior authorization?

At minimum: your current BMI (height and weight recorded in the chart); if your BMI is 27–30, documentation of a qualifying weight-related condition (hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, or cardiovascular disease); records of a supervised diet-and-exercise program, commonly ~90 days, with dates and what it involved; your baseline weight recorded at initiation; and, if your plan requires step therapy, documentation of the prior drug trial and its outcome (weight loss achieved or intolerance).

Do Ozempic and Mounjaro need prior authorization too?

Yes, but the criteria differ because they are diabetes drugs. For Ozempic and Mounjaro, prior authorization centers on documenting type 2 diabetes (a diagnosis and often A1c values), and sometimes a prior metformin trial — not weight-loss criteria. Using a diabetes-labeled drug purely for weight loss is off-label, and plans typically will not cover that use. If you have diabetes, the PA is usually straightforward with the right chart documentation.

What is a peer-to-peer review and should I ask for one?

A peer-to-peer is a direct phone conversation between your prescriber and the plan's medical reviewer. It often resolves denials caused by missing clinical context faster than a written appeal — your prescriber can explain your history, confirm you meet criteria, and cite the evidence. If your initial PA is denied for anything other than a flat benefit exclusion, asking your prescriber to request a peer-to-peer is usually the highest-yield next step.

What if my GLP-1 prior authorization is denied?

A denial is not the end. First, get the exact denial reason in writing — it's usually missing documentation, not meeting the criteria, a formulary exclusion, or step therapy. Then match your response: submit the missing records, request a formulary exception if the drug is non-preferred, or file a formal appeal (you have internal-appeal and independent external-review rights). Your prescriber can also request a peer-to-peer review. See our denial-appeal guide for the exact steps and deadlines.

Can my plan just refuse to cover weight-loss drugs entirely?

Yes — and this is different from a PA denial. Many employer plans simply exclude weight-loss medications from the benefit design, and Medicare Part D is barred by law from covering drugs used for weight loss. In that case, meeting the clinical criteria won't help, because it isn't a criteria question. Your options become: pursue coverage for a non-weight-loss indication (diabetes, cardiovascular risk with Wegovy, or sleep apnea with Zepbound), check the Medicare GLP-1 Bridge if you're on Medicare, or use cash-pay pricing.

Sources

Criteria reflect typical commercial PBM policies (OptumRx, UnitedHealthcare, and plan medical policy documents) and the FDA-label reassessment rules; appeal rights from HealthCare.gov/CMS. Exact thresholds vary by plan and revise quarterly. Reviewed 2026-07-18. Educational only — confirm your plan's policy.

References(5)

Our sourcing standards →

OptumRx — GLP-1 Receptor Agonists Prior Authorization criteria (BMI, lifestyle, >5% reauth) — OptumRx (PBM medical policy) (2026)
UnitedHealthcare — Weight Loss (GLP-1) Prior Authorization notification — UnitedHealthcare (commercial) (2026)
Weight-Loss (GLP-1) agents — medical policy criteria (BMI thresholds, lifestyle documentation) — Medical Mutual (plan policy) (2026)
Wegovy & Zepbound Prescribing Information — FDA indications and continuation/stopping criteriaNIH — US FDA labels via DailyMed (2026)