Free template tool
A GLP-1 prior authorization letter must document the diagnosis, BMI, weight-related comorbidities, prior lifestyle and pharmacotherapy attempts, and the requested medication. Fill in patient details below; the payer-ready letter updates live for Wegovy, Zepbound, Ozempic, or Mounjaro. Copy, download, or print and send to your prescriber to sign.
Patient name, DOB, insurance carrier, primary diagnosis, height/weight, A1C if applicable, and documented comorbidities. The BMI calculation updates live and flags whether your numbers meet the FDA threshold for weight-management GLP-1s.
Most payers require 6+ months of structured lifestyle intervention. Select any prior weight-management medications trialed (metformin, phentermine, Contrave, Qsymia). Empty interventions weaken the medical-necessity argument.
Prescriber name, NPI, phone, and fax appear in the letter header so the payer can route follow-up questions correctly. Leave blank to print bracketed placeholders your prescriber fills in by hand.
The right panel shows the draft letter updating in real time. Edit form fields to refine; the letter regenerates instantly. Click Copy to clipboard, Download .txt, or Print to PDF when ready.
The letter must be submitted by the prescriber, not the patient. Forward it via patient portal, email, or print and bring to your next visit. Most prescribers will edit and finalize within 1–3 business days.
Prior authorization (PA) is an approval step insurance plans require before covering certain medications. For GLP-1 weight-management drugs (Wegovy, Zepbound), nearly every commercial plan and Medicare Part D requires PA with documentation of BMI ≥30 (or ≥27 with a weight-related comorbidity), 6+ months of lifestyle intervention, and clinical justification for the prescription.
No — prior auth letters must be submitted by the prescriber on their letterhead, not by the patient. Use this generator to produce a draft, then send it to your prescriber to review, edit, sign, and submit through the standard PA channels (fax, payer portal, or CoverMyMeds).
No. All data is processed in your browser. We do not POST to our servers, set cookies, or log any form values. The letter is generated locally; only the .txt download leaves your device when you trigger it.
Commercial plans typically respond in 1–7 business days. Medicare Part D approvals often take longer (up to 14 days for standard, 24 hours for expedited). Approvals last 6–12 months and require renewal with updated weight and adherence data.