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.