Prior Authorization for Medications Template: Ozempic, Wegovy, and GLP-1s

[Date]

[Insurance Company Name]
[Insurance Company Address]
[City, State, Zip Code]

Subject: Prior Authorization Request for [Patient's Full Name] - [Medication Name]

Patient Information:
*   Patient Name: [Patient's Full Name]
*   Date of Birth: [MM/DD/YYYY]
*   Insurance ID/Member ID: [Patient's Insurance ID Number]
*   Group Number: [Patient's Group Number]
*   Address: [Patient's Full Address]
*   Phone Number: [Patient's Phone Number]

Prescriber Information:
*   Prescriber Name: [Your Full Name/Physician's Full Name]
*   NPI: [Your NPI Number]
*   DEA Number: [Your DEA Number (if applicable)]
*   Practice Name: [Your Practice Name]
*   Practice Address: [Your Practice Address]
*   Practice Phone Number: [Your Practice Phone Number]
*   Practice Fax Number: [Your Practice Fax Number]

Medication Requested:
*   Medication Name: [e.g., Ozempic (semaglutide), Wegovy (semaglutide)]
*   Dosage: [e.g., 0.5 mg, 1.0 mg, 2.0 mg, 2.4 mg] once weekly
*   Route: Subcutaneous injection
*   Quantity: [e.g., 1 pen] per [e.g., 28 days]
*   NDC: [National Drug Code, if required by insurer]

Diagnosis Information:
*   Primary Diagnosis: [e.g., Type 2 Diabetes Mellitus (ICD-10: E11.9), Obesity (ICD-10: E66.9)]
*   Relevant Comorbidities (if applicable):
    *   [e.g., Established Cardiovascular Disease (ICD-10: I25.10)]
    *   [e.g., Hypertension (ICD-10: I10)]
    *   [e.g., Dyslipidemia (ICD-10: E78.5)]

Clinical Justification for Medical Necessity:

Dear [Insurance Company Name] Review Board,

I am writing to request prior authorization for [Medication Name] for my patient, [Patient's Full Name], born on [Patient's Date of Birth]. This medication is medically necessary for the treatment of [Patient's Primary Diagnosis] and associated comorbidities, as detailed below.

[Patient's Full Name] has a documented history of [Patient's Primary Diagnosis] since [Date of Diagnosis]. Despite trials of conventional therapies, the patient has not achieved adequate therapeutic control, necessitating the use of [Medication Name].

Relevant Medical History:
*   [Summarize patient's relevant medical history, including duration of condition, previous treatments, and response. For example: 
    *   *Patient was diagnosed with Type 2 Diabetes Mellitus on [Date]. Initial treatment included Metformin [Dosage] for [Duration], which was discontinued due to [reason, e.g., gastrointestinal intolerance/insufficient glycemic control]. Subsequent trial of Sulfonylurea [Medication Name] for [Duration] also failed to achieve target HbA1c levels, currently [HbA1c level].*]

Supporting Clinical Data:
*   Recent Laboratory Results (Date: [Date of Labs]):
    *   HbA1c: [HbA1c %]
    *   Fasting Plasma Glucose: [FPG mg/dL]
    *   BMI: [BMI kg/m²]
    *   [Other relevant labs, e.g., Lipid Panel, Renal Function Tests]

Rationale for [Medication Name] (e.g., Ozempic/Wegovy):
[Medication Name] is a GLP-1 receptor agonist indicated for [e.g., improving glycemic control in adults with type 2 diabetes / chronic weight management in adults with obesity or overweight with at least one weight-related comorbidity]. Given [Patient's Full Name]'s [e.g., uncontrolled HbA1c despite maximal tolerated oral agents / BMI of X with comorbidities], [Medication Name] is the most appropriate therapeutic choice. It offers the benefits of [e.g., significant HbA1c reduction, weight loss, cardiovascular risk reduction] which are crucial for this patient's overall health and prognosis.

Previous Treatment Attempts and Failures (Step Therapy Compliance):
*   [List previous medications tried, dosages, duration, and reasons for failure or intolerance. For example:
    *   *Metformin [Dosage]: Initiated [Date], discontinued [Date] due to [e.g., severe gastrointestinal side effects / inadequate glycemic control (HbA1c remained >7.0%)].*
    *   *Sulfonylurea [Medication Name] [Dosage]: Initiated [Date], discontinued [Date] due to [e.g., hypoglycemia / weight gain / inadequate efficacy].*]
*   [If applicable, state contraindications to other formulary alternatives.]

Treatment Plan and Expected Outcomes:
We plan to initiate [Medication Name] at [initial dosage] and titrate as per manufacturer guidelines to achieve optimal therapeutic effect. Our treatment goals include:
*   Achieve target HbA1c of <7.0% (for T2DM).
*   Achieve clinically significant weight loss of >5% of body weight.
*   Reduce cardiovascular risk factors.
*   Improve overall metabolic health.

We will monitor [Patient's Full Name]'s progress closely, including regular HbA1c, weight, and blood pressure measurements, and assess for any adverse effects.

Attestation:
I attest that the information provided is accurate and complete to the best of my knowledge. I confirm that [Medication Name] is medically necessary for [Patient's Full Name] based on their clinical presentation and medical history.

Thank you for your prompt attention to this prior authorization request. Please do not hesitate to contact my office if you require any further information.

Sincerely,

[Your Full Name/Physician's Full Name]
[Your Title]
[Date]

STEP 1: Patient Needs Medication -> Prescriber Initiates PA Request
STEP 2: HealOS Benefits Verification Agent -> Checks Eligibility & Coverage
STEP 3: HealOS Clinical Documentation Agent -> Gathers & Structures Patient Data
STEP 4: HealOS Prior Authorization Agent -> Submits PA Request to Payer
STEP 5: Payer Review -> Approval OR Denial
STEP 6a: If Approval -> Medication Dispensed -> Patient Receives Medication
STEP 6b: If Denial -> HealOS Denial Management Agent -> Analyzes & Appeals Denial -> Loop back to Payer Review