Prior authorization letter template: GLP-1 for obstructive sleep apnea

[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: Moderate-to-severe obstructive sleep apnea (ICD-10: G47.33) with obesity (ICD-10: E66.x)

To whom it may concern:

I am requesting prior authorization for [drug name] for moderate-to-severe obstructive sleep apnea in a patient with obesity.

Clinical justification:
1. Sleep study on [date]: AHI of [value], confirming [moderate/severe] OSA.
2. BMI of [value] meets the labeled indication.
3. [Drug name] is FDA-approved for this indication; pivotal trials demonstrated significant AHI reduction.
4. CPAP status: [using CPAP — this therapy is adjunctive / unable to tolerate CPAP, documented attempts on dates].
5. Comorbidities aggravated by untreated OSA: [hypertension, atrial fibrillation, daytime somnolence affecting safety].

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

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