Prior authorization (PA) is a requirement from insurance companies that a prescriber obtain approval before a covered medication is dispensed. It exists ostensibly to ensure medications are prescribed for appropriate indications, but in practice it also controls costs by creating barriers that reduce prescribing of expensive medications. For GLP-1 medications and testosterone replacement therapy, prior authorization is often a significant hurdle.

How Prior Authorization Works

When your prescriber writes a prescription for a medication that requires PA, the pharmacy typically informs you that PA is needed before it can fill the prescription. Your prescriber’s office then submits a PA request to your insurer, which includes:

  • Clinical documentation supporting medical necessity (diagnosis codes, relevant lab values, medication history)
  • Attestation that the patient meets the criteria specified in the insurer’s PA policy

The insurer reviews the request and either approves, requests additional information, or denies.

Timeframes: Insurers are generally required to process standard PA requests within 72 hours and urgent requests within 24 hours, though appeals and resubmissions can extend the process significantly.

PA for GLP-1 Medications (Wegovy, Zepbound)

Insurance policies for GLP-1 weight loss medications typically require:

Documentation of BMI: Wegovy requires BMI 30+ or 27+ with qualifying comorbidity. Insurers require documented BMI from a clinical visit, not self-reported.

Qualifying comorbidities: For the 27+ threshold, the comorbidity (hypertension, sleep apnea, type 2 diabetes, dyslipidemia) must be documented in the medical record. The prescriber must include the relevant diagnosis code.

Prior weight loss treatment attempts: Many plans require documentation that the patient has attempted lifestyle modification (dietary counseling, exercise program) without adequate response. What constitutes “adequate trial” is defined in the insurer’s policy and varies.

Step therapy: Some plans require trying an older, cheaper medication first (often metformin for patients with prediabetes) before approving GLP-1 medications.

Exclusions: Many employer-sponsored plans have blanket exclusions for weight loss medications, including GLP-1 drugs, under wellness or lifestyle categories. These exclusions cannot be overridden with PA documentation, the benefit simply does not exist in the plan.

PA for Testosterone Replacement Therapy

PA for testosterone typically requires:

Two lab confirmations: Two morning testosterone measurements below the lab’s reference range, usually with at least one week between tests.

Symptom documentation: Clinical notes documenting hypogonadism symptoms.

Exclusion of secondary causes: Some plans require documentation that secondary causes (pituitary disorder, prolactinoma) have been evaluated.

Testosterone prescribing through telehealth platforms without adequate documentation often fails PA review because the clinical record is insufficient.

What to Do When Denied

Understand the denial reason: Insurers must provide a specific reason for denial. The explanation of benefits (EOB) or the denial letter specifies whether it was denied for missing documentation, a step therapy requirement, or an exclusion.

Request a clinical review or peer-to-peer: Prescribers can request a peer-to-peer review in which your doctor speaks directly with the insurer’s medical director. Peer-to-peer reviews increase approval rates in cases where documentation was inadequate or the medical necessity is strong.

File a formal appeal: If denied after peer-to-peer, a formal appeal allows submission of additional clinical evidence. First-level appeals are reviewed internally by the insurer. If denied again, external appeal to an independent review organization is typically available.

State insurance commissioner complaint: If appeals are denied and you believe the denial is improper, filing a complaint with your state’s insurance commissioner creates a regulatory record and sometimes prompts insurer reconsideration.

Apply for manufacturer assistance programs: Novo Nordisk’s Wegovy savings program and Eli Lilly’s Zepbound savings program can dramatically reduce cost for patients who qualify, often to $0 or minimal copay for commercially insured patients who are denied full coverage. Uninsured patients may qualify for patient assistance programs.

For the cost of GLP-1 medications without insurance coverage, see How Much Does Semaglutide Cost Without Insurance?. For guidance on getting an initial prescription, see How to Get Semaglutide Prescribed: Every Option Explained.