United States · Coverage

Renewing GLP-1 coverage in the US: a prior-authorization checklist

If your plan covers a GLP-1 medication, the approval usually has an end date. This guide explains how prior-authorization renewals work, shows one dated example of what a large pharmacy-benefit manager asks for, and lists your appeal rights. It can't tell you whether your renewal will be approved — only your plan decides that.

What prior authorization is

HealthCare.gov defines preauthorization as a decision by your plan that a service or prescription drug is medically necessary, and notes it is not a promise that the plan will pay^[1]. In 2024, every federally facilitated Marketplace plan that covered GLP-1 drugs approved for obesity required prior authorization^[4].

Approvals end, and renewals ask for evidence

One public example: CVS Caremark's standard tirzepatide weight-management criteria (reference 6947-C, dated March 2026) approve 8 months of initial therapy and 12 months on continuation. For continuation they ask that the person has been on a stable maintenance dose for at least 3 months and has lost at least 5% of baseline body weight, or kept off an initial 5% loss^[2]. Plan sponsors can use different criteria, so this is an illustration, not your plan's rules.

What to gather before your approval ends

A practical list, built from the kinds of items criteria like the example above ask about. Your prescriber's office submits the request; this just helps you have the facts ready:

• Your approval letter: the drug, the approval start and end dates, and the plan's reference number.
• Your starting weight and the date it was measured, and your most recent weight and date.
• When your current dose started (your prescriber's records are the source).
• Your plan's current criteria document or form, if your plan publishes it.
• The date to call your prescriber's office — well before the approval ends.

To keep track of these in one place, use the coverage renewal brief — a blank checklist that keeps the dates apart and prints a summary for your prescriber. It stays in your browser.

If a renewal is denied

Under the rules HealthCare.gov describes, you must file an internal appeal within 180 days of the denial notice, and an appeal about a drug you haven't received yet must be decided within 30 days^[3]. If the internal appeal is denied, you can request an external review in writing within 4 months; standard reviews are decided within 45 days and expedited ones within 72 hours, and the insurer must accept the reviewer's decision^[5].

A 2024 federal rule sets faster prior-authorization deadlines for some plans, but those deadlines do not apply to prior authorization for drugs^[6].

Questions to ask your plan, or your prescriber's office, after a denial:

• Which criterion wasn't met, or which document or measurement was missing?
• Can my prescriber send more information or a new request instead of an appeal?
• What is my deadline to file an internal appeal, and how do I file it?
• How long will a decision take, and is there a faster route if I would run out of medication?
• If the internal appeal is denied, how do I ask for an external review?

Asking doesn't change the rules or promise a different decision. It helps you and your prescriber see what's missing.

General information, not legal, insurance or medical advice. Only your plan can tell you its criteria and decide a renewal.