Prior Authorization Appeal Letter Template for GLP-1 Drugs

[Your Name]
[Your Address]
[City, State ZIP]
[Your Phone Number]
[Your Email]

[Date]

[Insurance Company Name]
Appeals and Grievances Department
[Insurance Company Address]
[City, State ZIP]

RE: APPEAL OF PRIOR AUTHORIZATION DENIAL
[For urgent appeals, add: URGENT APPEAL - EXPEDITED REVIEW REQUESTED]

Patient Name: [Your Full Name]
Date of Birth: [MM/DD/YYYY]
Policy/Member ID: [Your Insurance ID Number]
Group Number: [If applicable]
Claim/Reference Number: [From denial letter]
Date of Denial: [MM/DD/YYYY]

Medication Denied: [Ozempic (semaglutide) / Wegovy (semaglutide) / Mounjaro (tirzepatide) / Zepbound (tirzepatide)]
Prescribing Physician: [Doctor Name, MD/DO]
Diagnosis: [Type 2 Diabetes Mellitus (E11.9) / Obesity (E66.9) / Both]

Dear Appeals Review Committee:

I am writing to formally appeal the denial of prior authorization for [drug name], which my physician, [Doctor Name], has prescribed as medically necessary treatment for my [Type 2 Diabetes / Obesity / comorbid diabetes and obesity].

Your denial letter dated [date] states the reason for denial as: "[Quote exact denial reason from letter]." I am appealing this decision based on medical necessity, clinical evidence, and my specific health circumstances detailed below.

I. MY MEDICAL CONDITION AND URGENCY

I am a [age]-year-old [gender] diagnosed with [condition] in [year]. Despite treatment with multiple medications, my condition remains inadequately controlled and poses serious health risks:

• Current A1C: [X.X]% (most recent: [date]) - significantly above goal of <7.0%
• Current BMI: [XX.X] - [height: X'X", weight: XXX lbs]
• Blood Pressure: [XXX/XX mmHg] - [controlled/uncontrolled]
• Duration of Condition: [X years] with worsening control despite compliance

Current Complications/Comorbidities:

• [Check and detail all that apply:]
  • [ ] Diabetic neuropathy causing [pain/numbness] in [extremities]
  • [ ] Diabetic retinopathy with [vision changes/eye damage]
  • [ ] Diabetic nephropathy with [proteinuria/declining kidney function - eGFR: XX]
  • [ ] Cardiovascular disease: [hypertension/dyslipidemia/prior MI or stroke]
  • [ ] Obstructive sleep apnea requiring CPAP
  • [ ] Non-alcoholic fatty liver disease (NAFLD)
  • [ ] Severe joint disease limiting mobility

Why Immediate Treatment Is Critical:

Delaying effective treatment for 6-18 months while trialing additional medications that have already proven inadequate or intolerable poses unacceptable risk of:

• Progression of existing diabetic complications (nerve damage, vision loss, kidney failure)
• Irreversible organ damage from prolonged uncontrolled diabetes and obesity
• Cardiovascular events (heart attack, stroke) - my risk is elevated due to [diabetes duration >10 years / family history / existing CVD]
• Further weight gain exacerbating comorbidities and limiting treatment options

II. PRIOR MEDICATIONS TRIED AND FAILED

Contrary to the denial citing step therapy requirements, I have already trialed multiple medications that your policy requires, with documented inadequate efficacy or intolerable side effects:

1. Metformin

• Trial Period: [Dates: MM/YYYY to MM/YYYY]
• Dosage: [Up to XXXX mg daily]
• Outcome: [Choose applicable:]
  • [ ] Inadequate efficacy: A1C remained [X.X]% despite maximum tolerated dose and compliance
  • [ ] Intolerable side effects: Severe gastrointestinal distress (nausea, chronic diarrhea, abdominal pain) requiring discontinuation
  • [ ] Medical contraindication: [Chronic kidney disease (eGFR XX) / liver disease / lactic acidosis risk]
• Documentation: See attached pharmacy records and physician notes

2. [Sulfonylurea - specify: glyburide/glipizide/glimepiride] (if applicable)

• Trial Period: [Dates]
• Dosage: [XX mg daily]
• Outcome: [Choose applicable:]
  • [ ] Inadequate efficacy: A1C improved minimally to [X.X]%, still above goal
  • [ ] Intolerable side effects: Frequent hypoglycemic episodes ([X times per week]), weight gain ([XX lbs in X months])
  • [ ] Safety concerns: Hypoglycemia risk unacceptable due to [occupation requiring alertness / living alone / elderly age]

3. [Other medications trialed]

• [List any DPP-4 inhibitors, SGLT-2 inhibitors, insulin, or weight loss medications tried with dates, doses, and outcomes]
• Example: "Sitagliptin (Januvia) 100mg daily from [date] to [date]: A1C reduced only 0.3% to [X.X]%, inadequate for control."

Summary: I have exhausted [number] of the medications required by your step therapy protocol. Requiring additional trials of similar agents with proven inadequacy is not medically justified and delays necessary treatment.

III. MEDICAL NECESSITY AND EVIDENCE FOR [DRUG NAME]

[Drug name] is FDA-approved specifically for [Type 2 Diabetes / Obesity] and represents the appropriate next step in my treatment based on:

A. FDA Approval and Clinical Trial Evidence

For Ozempic/Wegovy (semaglutide):

• FDA Approval: Type 2 Diabetes (Ozempic, 2017), Obesity (Wegovy, 2021)
• SUSTAIN Trials: Demonstrated 1.5-2.0% A1C reduction vs 0.5-1.0% with older diabetes medications
• STEP Trials: Demonstrated 15% average weight loss vs 2-5% with older obesity medications
• SELECT Trial (2023): 20% reduction in major cardiovascular events (heart attack, stroke, cardiovascular death) - critical for high-risk patients like me

For Mounjaro/Zepbound (tirzepatide):

• FDA Approval: Type 2 Diabetes (Mounjaro, 2022), Obesity (Zepbound, 2023)
• SURPASS Trials: Superior A1C reduction (2.0-2.5% average) compared to other GLP-1 drugs
• SURMOUNT Trials: 15-21% average weight loss, superior to semaglutide
• Dual Mechanism: GLP-1 + GIP receptor agonism provides enhanced metabolic benefits

B. Professional Guidelines Support GLP-1 as Second-Line (Not Third/Fourth-Line)

• American Diabetes Association (ADA) 2024 Guidelines: Recommend GLP-1 receptor agonists as preferred second-line therapy after metformin for patients with established ASCVD, heart failure, or chronic kidney disease (I qualify due to [condition])
• American Association of Clinical Endocrinology (AACE): GLP-1 agonists recommended early in treatment algorithm for patients requiring significant A1C reduction or with obesity comorbidity
• Obesity Medicine Association: FDA-approved GLP-1 medications are first-line pharmacotherapy for obesity with BMI ≥30 or ≥27 with comorbidity

These guidelines from leading medical organizations do NOT support requiring 3-4 medication failures before accessing GLP-1 therapy. Your step therapy protocol conflicts with evidence-based medicine.

C. My Doctor's Clinical Judgment

My physician, [Doctor Name], a board-certified [Endocrinologist/Internal Medicine/Family Medicine] physician, has determined that [drug name] is the most appropriate medication for my specific clinical situation based on:

• My history of medication failures and intolerances
• My high-risk comorbidity profile requiring superior efficacy
• Cardiovascular and metabolic benefits specific to GLP-1 therapy
• Clinical evidence demonstrating superiority for patients like me

Please see the attached Letter of Medical Necessity from Dr. [Name] detailing the clinical rationale.

IV. FINANCIAL AND ACCESS CONSIDERATIONS

Cost-Effectiveness:

While [drug name] has higher acquisition cost than older medications, preventing diabetic complications and obesity-related hospitalizations represents significant long-term cost savings to the plan:

• Diabetic complications cost $16,752/year per patient (American Diabetes Association, 2023)
• Hospitalizations for DKA, heart attack, or stroke cost $15,000-$50,000+ per event
• Effective diabetes and weight control with GLP-1 therapy reduces these costs substantially

Manufacturer Savings Program:

I am enrolled in the [Novo Nordisk/Eli Lilly] savings card program which reduces my copay to $25/month IF coverage is approved. However, this program:

• Expires after 12 months (not sustainable long-term)
• Does not count toward my deductible or out-of-pocket maximum
• Can be discontinued at any time by the manufacturer

Insurance coverage is necessary for sustainable, long-term access to this medically necessary medication.

V. LEGAL AND REGULATORY CONSIDERATIONS

[If applicable - State Mandates]

As a resident of [California/Illinois/New York/Massachusetts], I am protected by state law requiring coverage of [obesity/diabetes] medications:

• California: SB 137 requires coverage of FDA-approved obesity treatments for BMI ≥30 or ≥27 with comorbidity. Your denial may violate California Health and Safety Code Section [XXXXX].
• Illinois: The Comprehensive Anti-Obesity Medication Access Act (2024) prohibits step therapy for FDA-approved obesity medications.
• New York: [Diabetes care mandate requires comprehensive coverage without excessive step therapy barriers.]

I am prepared to file a complaint with the [State] Insurance Commissioner if this medically necessary treatment continues to be denied in violation of state law.

[If applicable - Urgent Appeal Rights]

Given my [A1C >9% / existing diabetic complications / recent hospitalization], I qualify for EXPEDITED/URGENT appeal review under federal regulations (29 CFR 2560.503-1). This review must be completed within 72 hours as delaying treatment poses serious jeopardy to my life or health.

VI. REQUEST FOR PEER-TO-PEER REVIEW

I request that a board-certified [endocrinologist/obesity medicine specialist] employed by [Insurance Company] conduct a peer-to-peer review with my prescribing physician, Dr. [Name]. My doctor is available at [phone number] on [days/times] to discuss the clinical rationale for this prescription.

Many denials are overturned when a physician reviewer speaks directly with the prescribing doctor and reviews the complete clinical picture rather than relying solely on administrative criteria.

VII. CONCLUSION AND REQUEST

For the reasons detailed above, I respectfully request that you:

1. Reverse the prior authorization denial and approve coverage for [drug name and dosing]
2. Waive step therapy requirements as I have already trialed and failed required medications
3. [If urgent:] Process this appeal on an EXPEDITED basis given the serious health risks of further delay
4. Arrange peer-to-peer review between your medical director and my prescribing physician

This medication is:

• ✓ FDA-approved for my diagnosed condition
• ✓ Medically necessary based on my failed prior therapies and high-risk clinical profile
• ✓ Prescribed by a qualified specialist following evidence-based guidelines
• ✓ Supported by high-quality clinical trial evidence demonstrating superiority
• ✓ Critical to preventing irreversible health complications

Denying this medically necessary treatment violates my rights under my insurance policy and [state law, if applicable]. I trust that upon review of the complete medical evidence, you will approve this appeal.

I request a written response to this appeal within [30 days for standard appeal / 72 hours for urgent appeal] as required by law. If this appeal is denied, please provide:

• Detailed written explanation of the clinical rationale for denial
• Credentials of the reviewing physician who made the denial decision
• Information on my right to external independent review

Thank you for your prompt attention to this matter. I am available at [phone] or [email] if you require any additional information.

Sincerely,

[Your Signature]
[Your Printed Name]
[Date]

ENCLOSURES:

• Letter of Medical Necessity from [Doctor Name, MD/DO]
• Recent laboratory results (A1C: [date], lipid panel, kidney function)
• Pharmacy records documenting prior medication trials
• Original denial letter from [Insurance Company]
• [If applicable: Medical records documenting complications]
• [If applicable: State law citation and Insurance Commissioner contact information]

CC:

• [Doctor Name, MD/DO] - Prescribing Physician
• [If applicable: State Insurance Commissioner]
• [If applicable: Employer HR Department (for employer-sponsored plans)]