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Prior authorization navigator

Step-by-step guides for navigating insurance prior auth (PA) for hormonal medications. Requirements, timing, forms, appeal strategies per category.

GLP-1 for weight management

Wegovy / Zepbound

Typical PA requirements

  • BMI ≥ 30 OR BMI ≥ 27 + comorbidity (T2D, HTN, hyperlipidemia)
  • 6-month documented lifestyle intervention attempt
  • Step therapy: must try phentermine, orlistat, or contrave first (some plans)
  • Provider attestation of medical necessity

Timing

3-14 business days typical; expedited (24-72 hrs) for urgent.

Approval rate

~65% initial approval, ~85% after appeal with complete documentation

Forms: Plan-specific. Aetna PA portal, OptumRx PA, ExpressScripts PA. Some forms auto-populate from EMR.

Appeal strategy: Initial denial reasons: missing BMI documentation, lacking comorbidity proof, insufficient lifestyle attempt records. Appeal with complete documentation + medical necessity letter.

HRT for menopause

Estradiol patches, oral progesterone

Typical PA requirements

  • Documented vasomotor or genitourinary symptoms
  • Age + menopause status documentation
  • Often not required for generic HRT (tier 1)

Timing

1-5 business days typical when required.

Approval rate

~90%+ generic; <30% compounded

Forms: Not usually required for generic estradiol/progesterone. Required for compounded or non-formulary brands.

Appeal strategy: If denied for compounded HRT — switch to equivalent FDA-approved formulation usually approved.

Fertility (IUI/IVF medications)

Clomid, letrozole, gonadotropins, progesterone

Typical PA requirements

  • Infertility diagnosis (12+ months trying in age <35, 6+ in ≥35)
  • Treatment plan approved
  • State mandate coverage check (varies widely)

Timing

5-15 business days. State mandates affect timing.

Approval rate

~70-85% in mandate states; ~30-50% in non-mandate

Forms: Fertility-specific PA forms. Many require reproductive endocrinologist attestation.

Appeal strategy: Cite state mandate if applicable (NJ, IL, NY, MA, and others). Compare against ASRM treatment guidelines.

PCOS medications

Metformin, spironolactone, OCPs

Typical PA requirements

  • Diagnosis code (Rotterdam criteria documentation)

Timing

1-3 business days; often not required.

Approval rate

~95% (generics)

Forms: Standard formulary PA if non-formulary brand requested.

Appeal strategy: Generic alternatives almost always available and tier 1.

Non-hormonal vasomotor

Fezolinetant (Veozah)

Typical PA requirements

  • Documented VMS severity
  • HRT contraindication OR HRT failure OR patient preference
  • Often: prior step therapy with low-dose paroxetine

Timing

5-14 business days.

Approval rate

~50% initial; ~75% after appeal

Forms: Plan-specific. Astellas patient support can help.

Appeal strategy: Highlight HRT contraindication (e.g. breast cancer survivor) — usually approved.

Steps to take after a denial

  1. Read the denial letter carefully. Note specific reason (lacking documentation, step therapy, formulary tier).
  2. Request the full PA criteria for your plan. Insurance must provide upon request.
  3. Gather missing documentation — lab results, prior treatment records, clinical notes.
  4. Get a medical necessity letter from your prescriber addressing each denial reason.
  5. Submit a formal appeal with documentation. Most plans give 60-180 days.
  6. Escalate to external review if internal appeal denied. State insurance commissioner can help.

Also see insurance coverage matrix for plan-specific details.