Qualifying clinically and being funded are separate questions with separate answers. Plans generally add requirements on top of the medical criteria, and knowing them before you start saves a great deal of frustration.
A BMI at or above the threshold, recorded rather than reported. Where you are relying on the 27 threshold, the qualifying condition needs to be a diagnosis on file.
Many plans also want evidence of previous weight-management attempts, and some require step therapy, meaning another treatment tried first. Neither is a medical requirement; both are funding requirements.
And some workplace plans exclude weight-management drugs entirely, whatever your records say. That is worth establishing on day one rather than after a refusal. The detail sits in Is it covered, Qualifying conditions and Medication cost.
Documentation
The process
Getting a claim approved
Ask three questions
Is GLP-1 for weight management a covered benefit, is prior authorisation required, and what documentation is needed. Get the answers in writing if you can.
Assemble the file
Recorded BMI, the qualifying diagnosis, and any documented previous attempts. Gaps here are the most common reason for refusal.
Submit with clinical support
A prior authorisation supported by proper clinical notes is assessed very differently from a bare request.
Expect it to take time
Prior authorisation is rarely same-day. Build that into when you plan to start rather than being surprised by it.
If refused
What to do if a claim is refused
Ask for the reason in writing. Most refusals are documentation gaps rather than outright exclusions, and a gap can be filled and resubmitted.
Where the plan genuinely excludes weight-management medication, no amount of appealing changes it. At that point the honest conversation is about self-pay options and which molecule you can afford to stay on. Worth reading next: Program cost, Medication cost and Personalized plan.
Prior authorisation, documentation, timing and refusals.
Approval from your insurer before they will fund a medication. It usually requires documented BMI, a qualifying diagnosis and sometimes evidence of previous attempts, submitted with clinical support.
Rarely same-day, and it varies by plan. Assume it will take a while and start the process before you want to begin treatment rather than after.
Most often a documentation gap: a BMI not recorded, a diagnosis not on file, or previous attempts not evidenced. Ask for the reason in writing, because gaps can be filled and resubmitted.
Appealing an outright exclusion rarely works. The useful conversation is about self-pay: which molecule and which pharmacy make staying on treatment realistic for you.
The clinical documentation supporting a prior authorisation comes from the clinician. Submitting it and chasing the insurer is usually yours, and you will be told exactly what to send.
