Prior authorization (PA)

Prior authorization — often shortened to PA, and called preauthorization in the official HealthCare.gov glossary — is your insurer’s requirement that a prescription be approved before the plan will pay for it. Your clinician submits a request; a reviewer applies the plan’s criteria; the claim is approved or denied. Nearly every GLP-1 prescription in the United States goes through this.

What the reviewer is checking is whether you match the plan’s written criteria, which are usually narrower than the drug’s FDA label. Typical requirements include a documented BMI threshold, a weight-related condition, evidence of a supervised lifestyle attempt, and sometimes a trial of a cheaper drug first — that last one being step therapy. A prescription written for a use that is not the labeled indication, such as Ozempic for weight loss, is reviewed against a criteria set it was never going to meet.

The practical lever most people miss is that a denial is a first answer, not a final one. Medicare Part D has a defined process for coverage determinations, exceptions and appeals, and commercial plans have their own multi-level equivalents. Appeals succeed often enough that abandoning at the first denial is usually the wrong call.

The confusion worth clearing: prior authorization is not a medical judgment about you. It is a documentation match. Most denials turn on a missing chart note — an unrecorded BMI, an undocumented diagnosis code, a lifestyle program nobody wrote down — rather than on a reviewer disagreeing with your clinician.

Before your appointment, ask your plan for the written PA criteria for the specific drug, then ask your clinician to document each element explicitly. If you have established heart disease or sleep apnea, make sure that appears, since those support labeled indications. Our prior-auth letter generator and appeal strategy guide walk through the paperwork.