Free tool
Prior-authorization letter generator
Pick your insurer + medication. We auto-fill the published PA criteria + step-therapy requirements. You add your specifics, your prescriber reviews + signs, you submit to insurer.
Generated PA letter draft
Date: 2026-07-19 To: Aetna Prior Authorization Department Re: Prior Authorization Request for Mounjaro (tirzepatide) Patient: [Patient name] Member ID: [Member ID] Date of Birth: [DOB] Prescribing Provider: [Prescriber name, MD] NPI: [NPI number] Dear Prior Authorization Reviewer, I am writing on behalf of my patient [Patient name] to request prior authorization for Mounjaro (tirzepatide). The medication is medically necessary based on the following clinical findings: CLINICAL JUSTIFICATION: Diagnosis: [ICD-10 E11.x type 2 diabetes mellitus] A1C: [enter most recent A1C value, typically ≥7.0% qualifies] Duration of diabetes diagnosis: [years] PA CRITERIA ADDRESSED: 1. Documented type 2 diabetes diagnosis (ICD-10 E11) 2. Recent A1C lab value (typically ≥7.0%) 3. Trial + failure of metformin (or contraindication) 4. Provider attestation of medical necessity STEP-THERAPY DOCUMENTATION: The patient has trialed + failed (or has documented contraindication to) the following first-line therapies: - Metformin (first-line for type 2 diabetes per ADA guidelines) [Document specific drugs tried, dates, and reason for discontinuation] CLINICAL RATIONALE: Mounjaro (tirzepatide) is FDA-approved for type 2 diabetes management. My patient meets these criteria + has demonstrated inadequate response to first-line therapy. Mounjaro offers a documented improvement in glycemic control AND cardiovascular outcomes per published clinical trial data. I have reviewed the patient's complete medical history and confirm that the requested medication is medically necessary, appropriate, and aligned with FDA-approved indications + clinical guidelines. Please approve this prior-authorization request. If additional information is required, please contact my office directly. Sincerely, ___________________________ [Prescriber name, MD] NPI: [NPI number] [Office phone] [Office email] ATTACHMENTS (typically required): - Most recent labs (A1C / metabolic panel) - Documentation of step-therapy trial outcomes - Office visit notes establishing diagnosis - Any peer-reviewed evidence supporting medical necessity
What the Prior-auth letter generator does
This tool builds a prior-authorization (PA) letter draft for a GLP-1 medication. You choose an insurer and a drug from fixed lists, optionally type in patient and prescriber details, and the tool assembles a plain-text letter you can copy and hand to your prescriber. It covers six insurers (Aetna, Anthem, Blue Cross Blue Shield, Cigna, Humana, UnitedHealthcare) and four medications (Mounjaro and Ozempic, listed as type 2 diabetes drugs, and Wegovy and Zepbound, listed as weight-management drugs).
The letter is filled in from a stored coverage matrix, not from your actual plan documents. When you pick a diabetes drug, the tool inserts a diabetes-oriented criteria block: a type 2 diabetes diagnosis (ICD-10 E11), a recent A1C (the template notes ~7.0% or higher as the typical qualifying value), a trial and failure of metformin, and a provider attestation of medical necessity. When you pick a weight-management drug, it inserts a weight-loss block instead: BMI of 30 or higher, or 27 or higher with a weight-related comorbidity such as hypertension, dyslipidemia, sleep apnea, or type 2 diabetes; six or more months of documented diet and exercise; a note that the plan benefit must actually include obesity-treatment coverage; and a provider attestation with a supervised treatment plan.
It also drops in a step-therapy section (metformin for the diabetes drugs; a lifestyle program plus older anti-obesity medications like phentermine or Saxenda for the weight-loss drugs), a clinical-rationale paragraph referencing the drug's FDA-approved indication, a signature line, and a checklist of attachments reviewers usually want. The date is filled with the current date automatically. Everything runs in your browser; nothing is submitted to an insurer and nothing is saved.
The output is a starting template, not a finished or approved document. It is meant to save your prescriber's office typing time, not to make coverage decisions or to serve as medical or legal advice.
How to read your result
Read the generated letter as a first draft that still needs a clinician's hands on it. The bracketed placeholders like [Member ID], [NPI number], or [enter most recent A1C value] mark exactly what has to be replaced with real information before the letter means anything. The optional fields (patient name, member ID, date of birth, diagnosis code, A1C or BMI, prior medication trials, prescriber name, NPI) simply substitute into those spots as you type.
The criteria and step-therapy lines describe what PA reviewers commonly ask for by indication, not a promise that your specific plan uses these exact rules. Use them as a checklist: for each line, your prescriber should confirm your record actually supports it before the statement goes in. The tool's own on-screen warning is the operative instruction here, that your prescriber must review, edit to match your real clinical record, and sign, because inaccurate clinical statements can constitute insurance fraud.
The practical next step is to copy the draft, send it to whoever writes your prescription, and let their office adapt and submit it. If you want to know how likely coverage is before you go through this, the companion coverage matrix and insurance-readiness check on the site are better starting points, since this generator assumes you have already decided to pursue authorization.
What the result is based on
Every letter is assembled from two fixed data sets in the site's code: a list of insurer and medication names, and a coverage matrix that stores the PA-criteria text and step-therapy text used for each drug. The criteria are shared templates chosen by indication (one block for the diabetes drugs, one for the weight-loss drugs), so the clinical requirements shown are the same regardless of which of the six insurers you pick. The matrix records the facts as verified in Q2 2026 (dated 2026-06-01 in the source) and is intended to be updated quarterly.
The tool performs no calculation, scoring, or lookup against your plan. It is pure text assembly: your selections and typed text are merged into a preset letter structure. The A1C, BMI, and comorbidity numbers that appear are guidance text baked into the template, attributed to typical PA thresholds, not values the tool measures, validates, or pulls from any database.
What it cannot tell you
- It knows only six insurers and four drugs. Kaiser, Medicaid, Medicare Part D plans, Trulicity, Rybelsus, Saxenda as the requested drug, and compounded semaglutide or tirzepatide are all out of scope.
- The PA criteria are generic templates by indication, identical across all six insurers. It does not retrieve your plan's actual published criteria, your employer's specific rider, your formulary tier, or whether your benefit even includes obesity-treatment coverage, which is the single most common reason weight-loss drugs are denied.
- It does not verify anything you enter. The A1C, BMI, diagnosis code, and prior-medication history are free-text fields with no validation, so a wrong or unsupported number will pass straight into the letter.
- It cannot check your eligibility or predict approval. It produces the same letter skeleton whether or not you actually meet the criteria; deciding whether your record supports each statement is left entirely to your prescriber.
- It does not submit the request, track its status, or handle a denial or appeal. The letter is text you copy; the appeal pathway and denial reasons live elsewhere on the site, not in this tool.
- The stored criteria reflect a single verification date and can go stale between the quarterly updates the source file describes, so a plan's real requirements may have changed since.
Frequently asked questions
Does this letter get me approved or submit my request?
No. It only generates a text draft in your browser. Nothing is sent to your insurer, and the tool makes no coverage decision. You copy the draft, your prescriber reviews and signs it, and their office submits it.
Can I sign and send it myself?
No. A prior-authorization letter comes from the prescribing provider. The tool includes a prescriber signature line and NPI field for that reason, and its warning states plainly that your prescriber must review, edit to match your real record, and sign before submission.
Why are the criteria the same no matter which insurer I choose?
The tool stores one criteria template for diabetes drugs and one for weight-loss drugs, applied across all six insurers. Your specific plan may require more or different documentation, so treat the listed criteria as a common-case checklist, not your plan's exact rules.
Which medications and insurers does it support?
Four drugs, Mounjaro and Ozempic (handled as type 2 diabetes medications) and Wegovy and Zepbound (handled as weight-management medications), across Aetna, Anthem, Blue Cross Blue Shield, Cigna, Humana, and UnitedHealthcare. Anything outside those lists is not covered.
Where do the A1C and BMI numbers in the letter come from?
They are guidance text built into the template, describing thresholds PA reviewers commonly look for (for example, A1C around 7.0% or higher, or BMI 30, or 27 with a weight-related comorbidity). The tool does not measure or verify your values; you and your prescriber enter the real ones.
Is my information saved or shared?
No. The letter is assembled in your browser from your selections and typed text. There is no account, no submission, and no storage; if you close the page, the draft is gone.
What if my drug is covered as diabetes treatment but I want it for weight loss?
The tool assigns each drug a single indication, and the diabetes templates note that prescribing Mounjaro or Ozempic solely for weight loss is a common denial reason. That is a conversation to have with your prescriber, who decides how to document medical necessity accurately.
This tool is for education and planning. It does not diagnose, prescribe, or replace advice from a licensed clinician. Bring your result to a provider to decide what is right for you.