Prior authorization documents for weight loss treatment
A prior authorization request is a documents exercise rather than a phone call. The plan compares a written record against written criteria, so the file that gets approved is the one covering every item those criteria name. This page sets out what the items usually are, who supplies each, and where your plan publishes its criteria.
By the Covered Weight editorial team · Updated Aug 3, 2026. Research and sourcing by Evan Reid.
The file, item by item
Ten items. The prescriber produces seven of them because they are clinical records, and you produce three because the prescriber cannot. Read the right-hand column before an appointment: most requests that come back are missing a date or a dose rather than a document.
| What the file needs | Who supplies it | What plans look for |
|---|---|---|
| The completed prior authorization form for your plan | Prescriber | Plans publish their own form and most reject a request submitted on another plan's paperwork. The form number is on the plan's provider or pharmacy page. |
| The diagnosis, written as the plan words it | Prescriber | A plan pays for a drug against an indication, not against a molecule. The same drug can be approved for one condition and excluded for another on the same formulary, so the indication on the request is doing real work. |
| Height, weight and the measurement date | Prescriber | Recorded in the chart at a visit rather than reported by the patient. Plans that use a body mass index threshold read it from these two numbers, and an undated measurement is a common reason a request comes back. |
| The other conditions being treated, with their own diagnoses | Prescriber | Many plans set a lower body mass index threshold when a qualifying condition is documented. Which conditions qualify is a per-plan list, so the request names each one with its diagnosis rather than describing them. |
| The record of a supervised weight management program | Prescriber | Where a plan requires one, it usually wants dated visit notes rather than a statement that a program happened. What counts as supervised, and for how long, is set by the plan. |
| What has already been tried, with dates and what happened | Prescriber | This is the step therapy record. A plan that requires a cheaper drug first wants the dates it was taken, the dose reached, and why it was stopped. "Tried and failed" with no dates is the weakest line in most files. |
| Any reason a required earlier drug cannot be used | Prescriber | A documented reason a step-therapy drug is unsuitable is normally what a plan needs in order to skip that step. It is a clinical judgement recorded by the prescriber, never something a patient supplies. |
| Your pharmacy benefit card and member number | Patient | The pharmacy benefit is often administered separately from the medical benefit and carries a different number. Sending the request to the medical side is a routine cause of delay. |
| The plan document section that covers, or excludes, the benefit | Patient | On an employer plan this is the item that decides whether the rest is worth assembling. An outright exclusion means there are no criteria to meet. |
| The dated denial notice, if this is a resubmission | Patient | A resubmission answers the reason the plan gave. The notice names that reason and the reference number the plan files it under. |
That is a composite shape rather than any one plan's requirement list. Use it to find the gaps in a file, then check it against the criteria your own plan publishes, which the next section locates.
Where your plan publishes the criteria
A request is judged against a written test, and the test is published somewhere for every plan class. Which document holds it depends on who pays your claims, and so does whether you can read it before you file. Ask for the document by the name in the middle column: a request for "the criteria" often gets a summary, and a request for the named document usually gets the document.
| If your coverage is | The document holding the criteria | How to get it |
|---|---|---|
| Self-funded employer plan | your employer's plan document and Summary Plan Description | Ask your HR or benefits team for the full plan document and the Summary Plan Description, and read the section that lists exclusions. Weight-treatment exclusions are usually written there in one or two sentences. |
| Fully-insured employer plan | the insurance policy and its certificate of coverage, plus your state's insurance rules | Ask HR or the insurer for the certificate of coverage, then look up the insurer's medical policy for the treatment by name and number. |
| Marketplace plan | your plan's evidence of coverage, on top of your state's benchmark plan | Download the evidence of coverage and the formulary from your plan's member site, then check this site's page for your state's benchmark. |
| Medicaid | your state's preferred drug list and provider manual, plus your managed care plan's formulary if you have one | Look up your state program's preferred drug list, and if you are in a managed care plan, its formulary too. Both are published. |
| Medicare | your Part D plan's formulary, sitting under the federal definition of a covered Part D drug | Download your plan's formulary and its coverage determination request form from the plan's member site. |
| TRICARE or VA | the federal benefit regulation, plus the TRICARE or VA formulary | Check the TRICARE formulary search or the VA national formulary, and ask the pharmacy or the treatment team which criteria form applies. |
| State employee plan | the plan's benefit booklet, adopted by the state or local government that sponsors it | Download the benefit booklet and the pharmacy benefit documents from the plan's member site, and read the exclusions section. |
The middle and right columns are instructions for finding a document. They are not claims about what any document says, which is why they carry no citation: every sentence on this site that states what a document requires cites that document, and a citation attached to a sentence making no such claim would be provenance for nothing.
What this page does not have yet
It has no numbers. No body mass index threshold, no length of supervised weight management, no step-therapy order, no reauthorization interval. Those are per-payer values, they are read from a payer's own policy document one at a time, and none of them is published on this site yet.
The reason for the gap is worth stating, because every competing page fills it. A threshold is only true for the payer whose document it came from. Printed without that scope, one payer's test reads as the standard, and a reader who brings it to an appointment has been told something false about their own plan with a citation attached. The gap is narrower than a wrong number is deep.
What lands here as the criteria records are read: the threshold each payer applies, the conditions each payer accepts as qualifying, the step-therapy order in the order it runs, and the reauthorization interval, each with the document it came from and the date it was read.
If the request has already been denied
A denial names the criterion the plan says was not met, and that sentence is the whole agenda for what follows. Read how to appeal a weight loss drug denial for the forum your plan class appeals to and the order the steps run in. If your employer pays its own claims, start instead with self-funded employer plan coverage, because an outright exclusion in the plan document means there are no criteria to argue about.
Common questions
Does this checklist mean my plan will approve the request?
No. It is the shape of a complete file rather than a list of your plan's requirements. Your plan publishes its own criteria and its own form, and only the plan decides. A complete file removes the reasons a request is returned unread; it does not change the criteria.
Why are there no numbers on this page?
Because the numbers differ by plan, by benefit and by indication, and a threshold from one plan is wrong for the next. Covered Weight publishes a criteria value only from a named policy document, quoted, with the date we read it. Until those records exist, this page names the fields you will be asked about and not the values.
Who fills this in, me or my doctor?
Most of it is the prescriber's work, because it is clinical record-keeping rather than paperwork. The items marked for the patient are the ones the prescriber cannot produce: your plan documents, your benefit numbers, and any notice you have received.
What is the difference between prior authorization and step therapy?
Prior authorization is the plan requiring approval before it pays. Step therapy is one condition a plan can attach to that approval, requiring a documented trial of another treatment first. A plan can apply either, both, or neither, and the request has to answer whichever it applies.
How long does a decision take?
That is set by rules that vary with the plan class and with whether the request is urgent, and Covered Weight does not publish a timeframe it has not read at the governing document. The plan states its own timeframe when it acknowledges the request.