Prior authorization letter template: GLP-1 for cardiovascular risk reduction

[Date]

[Insurance company name]
Pharmacy Prior Authorization Department

RE: Prior authorization request
Patient: [Patient name], DOB: [DOB], Member ID: [ID]
Medication requested: [Drug name, strength, dosing]
Diagnosis: [Established cardiovascular disease, ICD-10 codes] with BMI [value] (ICD-10: E66.x / Z68.x)

To whom it may concern:

I am requesting prior authorization for [drug name] for secondary cardiovascular risk reduction.

Clinical justification:
1. The patient has established cardiovascular disease: [MI / stroke / PAD history with dates].
2. BMI of [value] meets the FDA-labeled indication for cardiovascular risk reduction with this agent.
3. A completed cardiovascular outcomes trial demonstrated a significant reduction in major adverse cardiovascular events in this population; this indication is FDA-approved.
4. Current risk-modifying therapy: [statin, antiplatelet, BP control, etc.] — the requested agent is additive, not a substitute.
5. Prior weight-management attempts and outcomes: [lifestyle program, other agents, duration, result].

Please contact my office at [phone/fax] for any additional documentation.

Sincerely,
[Prescriber name, credentials, NPI]
[Practice name and address]