The picture

PA design for GLP-1s is the single biggest source of member complaints in 2026 benefit programs. The 2024-2025 spike in GLP-1 demand exposed under-staffed PA teams. The fix is structural: standardize required documentation upfront (BMI, comorbidities, lifestyle attempt), provide a member-facing template to share with prescribers, target 3-5 business day turnaround, and proactively message appeal options when denials occur. Plans that publish PA criteria publicly see ~30% fewer escalations than plans that hide the rules behind member services.

Key statistics

PA approval rate (well-designed plans)

75-85%

PA approval rate (under-designed)

45-60%

First-appeal success rate

~35%

Member NPS impact of clear PA criteria

+12 to +18

Takeaways

Publish PA criteria publicly. Member-facing transparency reduces escalations.
Required documentation: BMI ≥ 30 with date, prior weight-loss attempt with documented timeline, comorbidity ICD-10 codes if BMI 27-30.
Aim for 3-5 business day turnaround. Anything past 10 days erodes plan NPS materially.
Provide member appeal templates pre-filled with the right citations.
Track PA approval rate by member segment to detect bias or process gaps.

Prior authorization for GLP-1s

Prior authorization for GLP-1s