Letter of Medical Necessity for a GLP-1 (Free Template)

the short answer

A letter of medical necessity is the document that most often turns a denial into an approval. It states who you are, your diagnosis, your BMI, your related conditions, what you have tried, and why this medication is appropriate. Here is a template you can adapt with your clinician.

what a strong letter includes

the template

letter of medical necessity, template

To Whom It May Concern,

I am writing on behalf of my patient, \[Patient Name\], date of birth \[DOB\], member ID \[ID\], to request coverage of \[Medication and dose\].

\[Patient Name\] has a diagnosis of \[diagnosis and code\], with a current BMI of \[BMI\] and a BMI of \[BMI at start\] at the start of therapy. They also have the following related conditions: \[conditions, for example high blood pressure, prediabetes, sleep apnea\].

We have previously tried \[prior treatments and outcomes\], which were \[ineffective or not tolerated\]. In my clinical judgment, \[Medication\] is medically necessary because \[rationale tied to the patient\].

I respectfully request approval of \[Medication and dose\]. Please contact me with any questions.

Sincerely,
\[Clinician name, credentials, NPI, contact\]

tips that make it land

a specific, well-documented letter is the single best tool in an appeal.

where it goes

Your clinician submits the letter with your prior authorization or appeal. Keep a copy for your records, and ask for the plan's decision in writing.

questions people ask

What is a letter of medical necessity?

A document from your clinician explaining why a medication is medically necessary for you, used to support coverage or an appeal.

Who writes it?

Your clinician writes and signs it, but you can prepare the details and a draft to make it easier.

Does a template guarantee approval?

No, but a complete, specific letter overturns a large share of denials, especially when paired with the right documentation.

What should I attach?

Records of your BMI, your diagnoses, and any past treatments you tried, so the plan can verify the case.

See if you qualify and get started

_This article is for education and is not medical advice. Coverage rules change often and vary by plan, state, and diagnosis; confirm current details with your plan or at cms.gov before acting. Reviewed by Dr. Linda Moleon, MD. If a GLP-1 might be right for you, talk with a licensed clinician._