What should a prior authorization letter include?

A complete prior authorization letter (Letter of Medical Necessity) should include: patient identifiers (name, DOB, member ID, plan name); the requested medication with strength, dose, and quantity; ICD-10 diagnosis codes; clinical history including failed prior treatments with dates and reasons; lab values supporting the diagnosis (HbA1c, BMI, etc.); peer-reviewed citations supporting the use; and the prescriber's signature, NPI number, and credentials. Most insurers require all of these elements; missing any one is a common reason for denial.

Who writes the prior authorization letter?

The prescribing physician must sign and submit the prior authorization. Patients cannot submit prior auths directly. However, you can prepare a draft letter and bring it to your doctor's appointment, give the doctor citations and documentation, and follow up with the prescribing office to ensure submission. Many practices have prior auth specialists who handle these — ask if your practice has one.

How long does prior authorization take?

Standard prior authorization decisions are required within 5–14 business days for most insurers. If marked urgent or expedited (when delay would cause harm), insurers must respond within 72 hours. Some plans use electronic prior authorization (ePA) tools that can return decisions within hours. If your prior auth is taking longer than 14 days, escalate by calling member services.

Can I appeal if my prior authorization is denied?

Yes. You have the right to appeal any denial. The first level is internal appeal to the insurer (deadline usually 180 days from denial). If denied again, you can request external review by an independent reviewer. Approximately 40% of appealed prior authorization denials are overturned, especially when accompanied by additional clinical documentation and peer-reviewed citations.

Do these templates work for all insurers?

The templates here are starting points based on common insurer requirements for the largest U.S. payers. Each insurer has slightly different forms and required fields — some require their proprietary PA form be submitted alongside any letter. Always check your insurer's portal for medication-specific PA forms; the templates supplement those forms with the clinical narrative that increases approval likelihood.

Home › Blog › Prior Authorization Templates

ToolsMay 2026 · 12 min read

Prior Authorization Letter Templates by Insurer (2026)

Prior authorization is the #1 reason GLP-1 prescriptions get denied. A well-written Letter of Medical Necessity submitted with the right clinical documentation can flip an automatic denial into an approval. Here are the templates.

These are starting points, not magic words. The doctor signs and submits — you can't submit your own PA. What you can do is bring a complete draft, all the clinical documentation, and the relevant citations to your appointment. That alone moves PAs from "maybe" to "approved" in most cases.

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This is not medical or legal advice. Templates are educational starting points. Your physician must complete, sign, and submit the prior authorization. Always check your insurer's portal for the exact required form for your specific medication.

What Every Prior Auth Letter Must Include

Patient identifiers — Full name, DOB, member ID, group number, plan name
Requested medication — Generic and brand name, strength, dose, quantity, frequency
ICD-10 diagnosis code(s) — Primary plus any relevant comorbidities
Clinical history — Date of diagnosis, severity, prior failed treatments with dates and reasons
Supporting lab values — HbA1c, BMI, fasting glucose, lipid panel, etc.
Treatment goals — Specific clinical outcomes the medication will address
Citations — 1–3 peer-reviewed studies or guidelines supporting the use
Prescriber credentials — Full name, NPI, DEA, license number, signature, date

Universal Prior Authorization Letter Template

Adapt this for any GLP-1 medication. Replace the gray [bracketed] placeholders with your details.

Letter of Medical Necessity · Template

[Date]

[Insurance Company Name]

Prior Authorization Department

[Address from your insurance card]

RE: Prior Authorization Request

Patient: [Full Name]

DOB: [MM/DD/YYYY]

Member ID: [from card]

Group #: [from card]

Dear Prior Authorization Reviewer,

I am writing to request prior authorization for [Medication Name], [Strength] [Dose] for [Patient Name], DOB [DOB].

Clinical Indication

[Patient Name] has a diagnosis of [Condition] (ICD-10: [Code]) documented since [Year]. Most recent labs:

— HbA1c: [Value]% (target <7%)
— BMI: [Value] (BMI ≥30 indicates obesity)
— [Other relevant values]

Prior Treatments Tried and Failed

[Drug 1] — [dates] — [reason for discontinuation/inadequate response]
[Drug 2] — [dates] — [reason]
Lifestyle modification: [duration, what was tried]

Clinical Rationale

[1–2 paragraphs explaining why THIS medication is the right choice NOW, including expected outcomes and how they tie to FDA-approved indications.]

Supporting Evidence

ADA 2024 Standards of Care recommend GLP-1 receptor agonists as preferred therapy for T2D with established cardiovascular disease or BMI ≥30 (Diabetes Care 47:S140-S157)
SELECT Trial (NEJM 2023): semaglutide reduced MACE by 20% in patients with obesity and CVD (DOI: 10.1056/NEJMoa2307563)
[Other relevant citations]

I respectfully request approval of this prior authorization. Please contact my office at [phone] with any questions.

Sincerely,

[Prescriber Full Name], [Credentials]

NPI: [Number]

DEA: [Number]

License #: [Number]

[Practice Address & Phone]

Insurer-Specific Notes

Blue Cross Blue Shield

Use BCBS prior auth form (varies by state plan). Strongest with HbA1c documentation, prior metformin trial.

Aetna

Aetna's PreCheck portal preferred for ePA. Step therapy with metformin or DPP-4 inhibitor often required for GLP-1.

Cigna/Express Scripts

Express Scripts manages most Cigna formularies. PA form 6064 commonly required for Ozempic. Step therapy required.

UnitedHealthcare/OptumRx

OptumRx PA portal. Coverage varies dramatically by employer plan. Letter should reference specific plan-issued formulary.

Humana

Humana Clinical Pharmacy Review unit. Medicare Advantage plans exclude weight-loss indications. T2D documentation essential.

Kaiser Permanente

Internal formulary committee. Submit through Kaiser physician network preferred. External requests often denied.

Common Denial Reasons and How to Pre-Empt Them

Step therapy not completed

Document failed trials of metformin, DPP-4 inhibitors, or other first-line agents with specific dates, doses, and reasons for discontinuation. If not tried due to contraindication, state the contraindication clearly.

Diagnosis not documented

Include ICD-10 code AND a one-sentence summary of how the diagnosis was confirmed (HbA1c testing, OGTT, BMI calculation with measured height/weight).

Off-label use

For GLP-1s, ensure you're matching the medication to the FDA-approved indication: Ozempic for T2D, Wegovy for chronic weight management with BMI ≥30 or BMI ≥27 with comorbidity.

Brand vs. generic

If a generic exists (lisdexamfetamine, sitagliptin), document why brand is medically necessary or accept the generic. Brand requests without justification are auto-denied.

Not formulary

Submit a formulary exception request alongside the PA. Reference the patient's prior failures with covered alternatives.

Check Your Coverage First

See what your specific plan requires for prior auth — in 60 seconds.

Check My Coverage →

Sources

AMA — Prior Authorization Practice Resources ↗

CMS — Prior Authorization Reform Final Rule (2024) ↗

AHIP — Prior Authorization Process Guide ↗

Related Guides

→ How to appeal an Ozempic denial → Ozempic coverage guide → All treatment guides