Prior Authorization Overview
At Midnight Arctic Sun Healthcare, we strive to make your care as seamless as possible. Prior authorization is a process used by some health insurance companies to determine if a service or medication is covered before you receive it. This ensures you get the right treatment while managing costs effectively.
When is it Needed?
Insurance typically requires authorizations for specific services within our telemedicine sessions, including:
- Specialized weight management medications
- Continuation of chronic care services
How to Request
Our clinic handles the submission for you. Once your provider determines a service requires authorization:
- We submit medical records to your insurer.
- You can track progress through our Patient Portal.
- We will notify you immediately once a decision is reached.
Have Ready
To speed up the process, please ensure we have your most current insurance card on file. You may also be asked for your primary care provider's contact information and any previous treatment history related to your current request.
Timeline
Standard authorizations typically take 7 to 14 business days to process, depending on your insurance carrier. Urgent medical requests are processed in a shorter timeframe where applicable. We recommend planning your follow-up visits accordingly to ensure no gaps in your treatment.
Prior Authorization Requirements for GLP-1 Weight Loss Medications
To ensure a safe, appropriate, and efficient prior authorization process, specific criteria and documentation are required before submission. Please review the following carefully.
Insurance Eligibility
- Prior authorizations are completed only for commercial insurance plans. The following insurance types are not eligible for prior authorization services through this practice:
- Health Maintenance Organizations (HMOs)
- Kaiser Permanente plans
- TRICARE
- Medicare
- Medicaid
- Medicare supplement plans
Clinical Eligibility Criteria
- To qualify for a prior authorization request, patients must meet one of the following criteria:
- BMI ≥ 30 without comorbid conditions
- OR
- BMI ≥ 27 with at least one documented comorbidity, including: Asthma, Polycystic ovarian syndrome (PCOS), Type 2 diabetes, Pre-diabetes, Hypertension, Hyperlipidemia, Fatty liver disease, Gastroesophageal Reflux Disease, Obstructive Sleep Apnea
- Patients with a BMI less than 27 are not eligible for prior authorization under any circumstances.
Continuation of Therapy
- If you are establishing care with this practice for continuation of a GLP-1 medication previously prescribed by another healthcare provider, all of the above clinical and documentation requirements still apply.
- In addition:
- Patients seeking continuation must have a current BMI ≥ 27 to be considered for ongoing therapy
- Prior treatment history must be supported with appropriate medical documentation
- Current weight and height verification requirements remain the same
- Continuation of therapy does not guarantee approval for prior authorization and must meet the same clinical and insurance criteria as new starts.
Required Documentation
- All clinical criteria must be supported with verifiable medical documentation. Acceptable forms include: Recent laboratory results, Medical records or visit notes from a prior healthcare provider
- Additionally, the following are required for submission:
- Scale photo documenting current weight
- Height verification, which must be provided through one of the following: Driver’s license, After-visit summary or medical record from a healthcare provider
- These elements are essential to accurately calculate and verify BMI for insurance review.
Medications Included in Prior Authorization Requests
- Up to two prior authorization submissions will be completed per patient for one of the following GLP-1 medications: Tirzepatide (Zepbound or Mounjaro), Semaglutide (Wegovy, oral or injectable), or Foundayo.
- If the initial prior authorization is denied, a second submission will be completed for an alternative GLP-1 medication.
Appeals Policy
At this time, appeals are not completed by the practice. If both prior authorization attempts are denied, patients may explore self-pay options. Manufacturer-supported pricing and programs are available and can be reviewed on the weight loss services page.