Tool · Letter templates
Prior authorization letter templates
Free, fill-in-the-blanks prior authorization letters for GLP-1 coverage, one per indication — built to bring to your prescriber.
Templates, not advice.
These are drafting aids to bring to your prescriber or send to your insurer — they are not
legal or medical advice, and your clinician should adapt the clinical details to your case.
Prior authorization letter template: GLP-1 for type 2 diabetes
For coverage of a GLP-1 (e.g., semaglutide, tirzepatide) prescribed for type 2 diabetes. Your prescriber sends this; the template helps you arrive at the appointment prepared.
Prior authorization letter template: GLP-1 for cardiovascular risk reduction
For coverage of semaglutide (Wegovy) where the indication is reducing major cardiovascular event risk in a patient with established heart disease and elevated BMI — the indication supported by the SELECT outcomes trial.
Prior authorization letter template: GLP-1 for obstructive sleep apnea
For coverage of tirzepatide (Zepbound) for moderate-to-severe obstructive sleep apnea with obesity — an FDA-approved indication since late 2024.