Prior authorization letter template: GLP-1 for type 2 diabetes

[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: Type 2 diabetes mellitus (ICD-10: E11.x)

To whom it may concern:

I am requesting prior authorization for [drug name] for the above patient with type 2 diabetes.

Clinical justification:
1. Current HbA1c: [value]% on [date], despite [current/prior regimen, e.g., metformin at maximally tolerated dose for X months].
2. [Drug name] is FDA-approved for type 2 diabetes and is indicated per the current ADA Standards of Care for patients with [relevant factors: established ASCVD, obesity/BMI, hypoglycemia risk on alternatives, etc.].
3. Prior therapies tried and outcome: [list medications, duration, result/intolerance].
4. Additional clinical factors: [BMI, comorbidities such as cardiovascular disease or CKD, contraindications to alternatives].

Treatment goal: [target HbA1c / weight / risk-reduction goal] with follow-up scheduled [interval].

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

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