Accepted answer
Almost every commercial GLP-1 prior authorisation is decided by an automated criteria engine first, and a human only touches it when the engine cannot approve. The pipeline has four stages, and knowing which one you are stuck in tells you what to do.
Stage 1 — intake and completeness
The request arrives by ePA (an NCPDP SCRIPT transaction from the prescriber's EHR), by the PBM's web portal, or by fax. ePA and portal submissions are structured: the form will not submit without the mandatory fields. Fax submissions are keyed by a technician, and this is where most of the invisible delay lives — an unreadable weight, a missing diagnosis code, or an attached progress note with no dated weights in it gets kicked to a "needs more information" queue rather than denied. A pend is not a denial, which matters: your appeal clock does not start until an adverse determination is actually issued, so a request that quietly sits in the pend queue can burn a month without ever giving you appeal rights.
Stage 2 — the criteria engine
The engine scores the submitted data against the plan's published coverage policy. For anti-obesity medication the criteria are unusually mechanical, which is good news — they are auditable. A typical commercial policy looks like this:
| Criterion | Typical threshold | What actually satisfies it in the chart |
|---|
| Age | 18+ (12+ for some plans on specific products) | Date of birth; automatic |
| Baseline BMI | ≥30, or ≥27 with a comorbidity | A dated height and weight in the same encounter, plus a Z68.xx BMI code |
| Qualifying comorbidity (for the 27–29.9 band) | Hypertension, dyslipidaemia, OSA, T2DM, MASLD, PCOS | An active ICD-10 problem on the list, not "history of" |
| Lifestyle intervention | 3 or 6 consecutive months, documented | Dated visits or a structured programme record covering the window |
| Step therapy | Trial of a preferred agent, or documented contraindication | Pharmacy claim history, or an intolerance note naming the drug, dose and reaction |
| Exclusions screen | MTC/MEN2 history, pregnancy, concurrent GLP-1 | Absence in the problem list; a prescriber attestation |
| Quantity / dose | Label titration schedule only | Written directions matching the approved escalation steps |
| Reauthorisation | Often ≥5% weight loss at 3–6 months | Dated on-treatment weights; this is the criterion people fail later |
If every row is satisfiable from structured data, the engine approves in minutes. If any row is unsatisfiable from structured data, it routes to a human.
Stage 3 — clinical review
A pharmacist (or a nurse reviewer) reads the attachments. A pharmacist reviewer can approve, and can pend for more information, but in most PBMs is not permitted to issue a medical-necessity denial. That authority sits with a medical director.
Stage 4 — medical director
Only a physician reviewer can sign an adverse medical-necessity determination. This matters for your appeal: you are entitled to know the reviewer's specialty, and at internal appeal you can usually request a peer-to-peer between your prescriber and that reviewer.
Getting the criteria in advance
Yes, and you should. Ask member services in writing for "the utilisation management criteria and the prior authorisation form used for [product] under my plan". Most PBMs publish these as PDFs; many plans are also obliged to supply them on request, and for an ERISA plan you can additionally request the plan documents the criteria derive from. Read the criteria before the resubmission, not after the denial. Eight times out of ten the failure is one unmet row, and it is a documentation gap rather than a clinical one.
On your timeline: eleven days with no adverse determination and no request for information is consistent with a pend that was never communicated. Have the office check the submission status in the portal rather than the EHR's outbound log, and ask the plan directly whether an adverse determination has been issued. None of this is medical advice; it is administrative plumbing.
edited 12 Mar 2025 by elke_brunner — updated for the 2026 guidance change
3The pharmacist-cannot-deny point is the single most useful thing here. It reframes who you are actually arguing with. – e_dziedzic 7 months ago 4Confirmed on my plan: the reauthorisation 5% rule caught me at month four because nobody recorded a weight in between. – ellis_thorne 8 months ago add a comment