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100+ payers · 800+ criteria docs · updated continuously

Prior authorization criteria API for GLP-1 medications.

A normalized API of prior-authorization criteria across 100+ payers. Every record is human-reviewed against its source policy, with source citations and dates where the policy provides them.

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How the data is built

  1. 01

    Sourced

    Coverage policies are identified per payer: PA policies, formulary documents, and published medical policies.

  2. 02

    Structured

    Criteria are extracted into normalized fields: thresholds, prerequisites, step therapy, durations.

  3. 03

    Verified

    A human reviewer confirms each record against its source and applies a dated verification stamp.

  4. 04

    Re-verified

    Each record carries a dated verification stamp; when a policy changes, the record is re-reviewed and prior provenance is preserved.

See the API in action

Read the API docs →

Three real responses from the production API: payer resolution, the per-plan-type coverage array, and the full criteria payload your integration receives.

Covered, but conditional on the member's benefit including weight-loss medications (coverage_scope: rider_required).

POST /coverage · 200 OK
{
  "query": {
    "payer": "Kaiser Permanente Colorado",
    "drug": "Wegovy",
    "indication": "weight_loss",
    "plan_type": "commercial"
  },
  "resolved": {
    "payer": {
      "payer_id": 44,
      "name": "Kaiser Permanente Colorado",
      "payer_type": "regional",
      "match_type": "exact_name",
      "confidence": 1.0,
      "mco_fallback": false
    },
    "drug": {
      "id": 2,
      "brand_name": "Wegovy",
      "generic_name": "semaglutide"
    }
  },
  "coverage": [
    {
      "plan_type": "commercial",
      "formulary": "HMO (all plans)",
      "formulary_varies": false,
      "coverage_state": "conditional_on_benefit",
      "is_covered": true,
      "is_preferred": false,
      "coverage_scope": "rider_required",
      "coverage_scope_note": "Patient must have benefit plan with coverage for weight loss medications",
      "basis": null,
      "requirements": {
        "age": {
          "min": 12,
          "max": null
        },
        "bmi": {
          "min": 30.0,
          "min_with_comorbidity": 27.0,
          "min_asian": null,
          "percentile_min": null
        },
        "a1c": {
          "min": null,
          "max": null,
          "for_combination_therapy": null
        },
        "step_therapy": {
          "requires_metformin_trial": false,
          "metformin_trial_duration_days": null,
          "metformin_exception_conditions": [],
          "requires_prior_glp1_trial": true,
          "prior_glp1_drugs": [
            "generic liraglutide (Victoza)"
          ],
          "prior_glp1_count_required": 1,
          "prior_weight_loss_drugs": [
            "phentermine",
            "diethylpropion",
            "Qsymia",
            "Contrave"
          ],
          "prior_weight_loss_trial_months": 3
        },
        "cardiovascular": {
          "requires_cv_disease": false,
          "cv_qualifying_events": [],
          "requires_gdmt": false,
          "gdmt_medications": []
        },
        "osa": {
          "requires_osa_diagnosis": false,
          "ahi_min": null,
          "requires_pap_trial": false
        },
        "mash": {
          "requires_mash_diagnosis": false,
          "fibrosis_stage_min": null,
          "fibrosis_stage_max": null,
          "confirmation_methods": []
        },
        "renal": {
          "egfr_min": null,
          "egfr_max": null,
          "uacr_min": null
        },
        "lifestyle": {
          "requires_program": false,
          "duration_months": null
        },
        "diagnosis": {
          "requires_diagnosis_code": false,
          "codes": [],
          "confirmation_methods": [
            "clinical_diagnosis"
          ],
          "requires_lab_verification": false,
          "excludes_diabetes": false
        },
        "comorbidities_accepted": [
          "HTN",
          "dyslipidemia",
          "T2DM"
        ],
        "exclusions": {
          "other": [
            "Concurrent use with another GLP-1 or GLP/GIP (e.g., tirzepatide) product",
            "Concurrent use of DPP-4 inhibitor (alogliptin, linagliptin, saxagliptin, sitagliptin)",
            "Step therapy failure exceptions do not apply for convenience or needle phobia",
            "Wegovy (semaglutide) tablets excluded per P&T",
            "Patient must have benefit plan with coverage for weight loss medications"
          ],
          "pregnancy": false,
          "type_1_diabetes": false,
          "bariatric_surgery": false
        }
      },
      "qualification_pathways": [
        {
          "all_of": [
            "Patient is 12 years of age or older",
            "Patient has benefit plan with coverage for weight loss medications",
            "Not currently using a DPP-4 inhibitor (alogliptin, linagliptin, saxagliptin, or sitagliptin)",
            "Patient will NOT use Wegovy with another GLP-1 or GLP/GIP (e.g., tirzepatide) product",
            "Current weight on file within the past 4 weeks (objectively measured in-office)",
            "BMI >= 30 kg/m2 OR (BMI >= 27 kg/m2 AND at least one weight-related comorbidity: hypertension, dyslipidemia, or type 2 diabetes)",
            "Provider attests patient is on a reduced calorie diet and has increased physical activity",
            "Documented intolerance, contraindication, or failure to lose and maintain at least 5% body weight after trial of all required step therapy agents, OR provider submits justification per criteria"
          ],
          "any_of": [
            "Step therapy completed in order: (a) phentermine 37.5 mg/day OR diethylpropion 75 mg/day for >= 3 months, then (b) Qsymia (phentermine 15 mg/topiramate 92 mg/day) for >= 3 months, then (c) Contrave (naltrexone 32 mg/bupropion 360 mg/day) for >= 3 months, then (d) generic liraglutide (Victoza) 3 mg/day for >= 3 months",
            "Provider justification: required drug(s) contraindicated or will likely cause adverse reaction/harm",
            "Provider justification: required drug(s) ineffective based on known clinical characteristics",
            "Provider justification: patient tried and failed required drug(s) or same-class agent, discontinued due to lack of efficacy, diminished effect, or adverse event",
            "Patient is stable on requested drug after completing step therapy or receiving a step therapy exception"
          ],
          "pathway_name": "Initial approval for weight loss (age 12+)"
        }
      ],
      "required_documentation": [
        "Current (within past 4 weeks) BMI (kg/m2) — objectively measured in-office weight check",
        "Documentation of weight-related comorbidities if BMI is 27-<30 kg/m2 (hypertension, dyslipidemia, or type 2 diabetes)",
        "Documentation of failed trials of step therapy agents (medication, strength, dates of treatment, reason for discontinuation) OR provider justification why alternatives are not suitable with supporting clinical documentation",
        "Provider attestation that patient is on a reduced calorie diet and has increased physical activity",
        "Confirmation that patient is not currently on a DPP-4 inhibitor",
        "Confirmation that patient will not use Wegovy concurrently with another GLP-1 or GLP/GIP product"
      ],
      "quantity_limits": [
        {
          "strengths": [
            "all strengths"
          ],
          "supply_28_day": "1 box / 4 pens / 3 mL (max daily dose 0.11 mL); renewal: 1 box / 1 pen / 3 mL per 28 days",
          "supply_84_day": null
        }
      ],
      "approval": {
        "initial_months": 6,
        "continuation_months": 12,
        "continuation_clinical_benefit": "Patient must have achieved and maintained at least 5% weight loss from baseline (objectively measured with in-office weight checks). BMI check within past 4 weeks required. Initial step therapy requirements (phentermine, Qsymia, Contrave, generic liraglutide trials) are NOT re-verified at renewal.",
        "continuation_weight_loss_percent": 5.0,
        "minimum_maintenance_dose_mg": null,
        "minimum_therapy_weeks": null
      },
      "provenance": {
        "source_type": "reviewed_policy",
        "documented": true,
        "effective_date": "2026-02-01",
        "expiration_date": null,
        "last_verified_at": "2026-06-05T14:01:33.189Z"
      }
    }
  ]
}
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Normalized fields, not PDFs

Every payer policy is decomposed into the same queryable structure, per drug, plan type, and indication.

PA required

Whether prior authorization is required, per drug × plan type × indication.

Step therapy

Required prior trials: metformin, other GLP-1s, and prior weight-loss agents, with durations.

BMI thresholds

Minimum BMI, BMI-with-comorbidity, and pediatric percentile cutoffs.

Qualifying comorbidities

Which conditions a payer accepts alongside a threshold BMI.

Clinical prerequisites

A1C minimums, lifestyle-program documentation, lab verification, specialist requirements.

Quantity limits & approvals

Initial and continuation approval durations, quantity limits, renewal criteria.

Age restrictions

Minimum and maximum ages per drug and indication.

Provenance

Effective date, source document and citation, last human verification, and capture status.

Built for teams that work with coverage data

The same structured criteria, applied wherever coverage decisions get made.

Pharma

Pharmaceutical market access

Payer-by-payer criteria intelligence for field reimbursement teams, value & access strategy, and coverage monitoring.

Telehealth

Telehealth & digital health

Qualify patients at intake, pre-build PA submissions, and stop losing conversions to coverage surprises.

Pharmacy

Specialty & retail pharmacy

Criteria at the point of dispensing to reduce PA rework and prescription abandonment.

Health tech

PA automation & health tech

Structured criteria as the rules engine behind your prior-authorization workflows.

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Or schedule a walkthrough of the data with your team.