MyGLP1Coverage MyGLP1Coverage / API documentation
Request API access

GLP-1 Coverage Criteria API

One request resolves a payer × drug × indication to its structured prior-authorization criteria: step therapy, BMI and A1C thresholds, qualification pathways, required documentation, quantity limits, approval durations, and provenance. You get one coverage entry per plan type, or just the plan type you ask for.

Every record is human-reviewed against the source policy document, dated, and re-verified on a rolling cycle. Criteria detail is only returned for reviewed records (provenance.source_type: reviewed_policy), and the API never converts policy silence into a coverage answer. Gaps come back as an explicit no_data verdict.

Two endpoints

POST /coverage — the criteria lookup. POST /resolve — map a card's plan name to the right payer first.

Payer resolution built in

Send the payer name as printed on the card; the API resolves it and reports match_type and confidence.

Seven explicit verdicts

Including no_data and off_label — honest gaps, never silent denials.

No PHI, structurally

Selectors travel in the JSON body, never the URL; unexpected fields are rejected, not ignored.

Base URL

Base URL
https://api.myglp1coverage.com/api/v1

All requests are HTTPS POSTs with a JSON body. Responses are JSON, UTF-8 encoded.

Authentication

Every request requires an API key, sent as a bearer token (Authorization: Bearer <key>) or in the X-Api-Key header. Keys are issued per organization — request access to get one.

Authenticated request
curl https://api.myglp1coverage.com/api/v1/coverage \
  -H "Authorization: Bearer $GLP1_COVERAGE_API_KEY" \
  -H "Content-Type: application/json" \
  -d '{ ... }'

Requests without a valid key receive 401. Usage is metered per request; exceeding your daily limit returns 429. Keep keys server-side; never embed them in client-side code.

No PHI, by design

The API accepts plan selectors only — never patient or clinical data — and the transport is built so that holds even by accident:

  • 01 Selectors travel in the JSON request body, never the URL. Any query-string parameter is rejected with 400 — edge infrastructure logs raw URLs before application-level filtering can run, so the API refuses to let anything ride in one.
  • 02 The request body is deny-by-default: any field outside the documented selector allowlist is rejected with 400, not silently ignored. A stray member_dob never makes it past the front door.

Payer resolution

You don't need to learn our payer keys. Send the payer name as it appears on the member's card — the API resolves it and reports match_type and confidence so your integration decides when to trust the match. Resolution handles the cases that actually break card-to-criteria mapping:

  • Product-name aliases that pin a line of business. "Cigna HealthSpring" resolves to Cigna and pins medicare_advantage, the line its criteria are actually filed under.
  • Medicaid managed-care fallback. An MCO plan name resolves to the state Medicaid program whose criteria govern it, flagged with mco_fallback.
  • Fail-loud, never fuzzy. Matching is exact (canonical names + curated aliases). A name that can't be matched to a specific payer returns no_match. For a PA gate, a wrong criteria set is worse than no answer.

Use POST /resolve to map a card name before a lookup, or just pass the name straight to /coverage — both resolve the same way. Responses include stable payer_id / drug_id values you can send on later requests to skip resolution entirely.

POST /resolve
curl https://api.myglp1coverage.com/api/v1/resolve \
  -H "Authorization: Bearer $GLP1_COVERAGE_API_KEY" \
  -H "Content-Type: application/json" \
  -d '{"name": "Cigna HealthSpring"}'
200 OK — alias pinned to a line of business
{
  "query": { "name": "Cigna HealthSpring" },
  "match": {
    "payer_id": 12,
    "name": "Cigna",
    "payer_type": "national",
    "match_type": "exact_alias_pinned",
    "confidence": 0.98,
    "resolved_plan_type": "medicare_advantage",
    "mco_fallback": false
  }
}

Coverage lookup

POST /coverage

Resolves the payer and drug, then returns one coverage entry per plan type the payer has criteria for — or only the requested plan_type. When a payer maintains more than one formulary and they disagree, the entry answers for the payer's default formulary and sets formulary_varies: true.

If the payer resolved via an alias that pins a line of business, a contradictory plan_type fails loud with 409 rather than silently answering for the wrong line. Medicare Part D and Medicare Advantage share PA criteria and are treated as one line.

Request body

JSON body fields for POST /coverage. Identify the payer by payer or payer_id, and the drug by drug or drug_id.

Field Type Description
payer required* string Payer name or alias as printed on the card, e.g. "Kaiser Permanente Colorado", "Cigna HealthSpring". (*or payer_id)
payer_id optional integer Stable payer id from a previous response or /resolve — skips name resolution.
drug required* string Drug brand or generic name, e.g. "Wegovy", "Ozempic". (*or drug_id)
drug_id optional integer Stable drug id from a previous response — skips name resolution.
indication required string One of: diabetes, weight_loss, cv_risk_reduction, mash, osa, ckd.
plan_type optional string One of: commercial, medicare_part_d, medicare_advantage, marketplace, medicaid, essential_plan, fep. Omit to receive one coverage entry per plan type.
formulary_id optional integer For payers that maintain more than one formulary. Defaults to the payer's default formulary when coverage varies.

Any other body field — and any query-string parameter — is rejected with 400. The fields bin, pcn, rx_group, and formulary are accepted without error but are reserved — they do not influence resolution today.

Example request

Wegovy for weight loss under Kaiser Permanente Colorado's commercial plans:

curl
curl https://api.myglp1coverage.com/api/v1/coverage \
  -H "Authorization: Bearer $GLP1_COVERAGE_API_KEY" \
  -H "Content-Type: application/json" \
  -d '{
    "payer": "Kaiser Permanente Colorado",
    "drug": "Wegovy",
    "indication": "weight_loss",
    "plan_type": "commercial"
  }'

Example responses

Three verbatim production responses. Together they show the resolution block, the per-plan-type coverage array, and the three most common verdict shapes: coverage conditional on benefit design, a preferred agent with standard requirements, and Medicaid criteria with condition-specific requirements.

Wegovy · weight loss · Kaiser Permanente Colorado (Commercial)

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

200 OK · application/json
{
  "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"
      }
    }
  ]
}

Coverage states

coverage_state is the verdict — the first thing to key integration logic off. The four stored states carry the full criteria payload; the three derived states are verdict-only entries.

State Payload Meaning
covered full Covered with no documented clinical gating.
covered_with_requirements full Covered once the documented criteria are met — thresholds, step therapy, pathways.
conditional_on_benefit full Covered only if the member's pharmacy-benefit design includes it (see coverage_scope / coverage_scope_note) — often an optional employer benefit.
not_covered full Excluded under this plan type and indication.
covered_under_diabetes_criteria verdict only Derived: an on-label, diabetes-restricted use is covered via the plan's diabetes criteria. Policy silence on the specific indication is never treated as a denial.
off_label verdict only The drug is not FDA-labeled for this indication; no policy basis exists.
no_data verdict only We haven't captured this combination yet — an honest gap, not a denial.

Field reference

Every field in the POST /coverage response. Paths under Coverage entries and below are relative to each element of the coverage[] array. A null threshold means the policy sets no such requirement.

Response envelope

Field Type Description
query object Echo of the selectors you sent (omitted keys are absent).
resolved.payer.payer_id integer Stable payer id — reusable as payer_id in later requests.
resolved.payer.name string Canonical payer name your input resolved to.
resolved.payer.payer_type string Payer category (e.g. national, regional, bcbs_independent).
resolved.payer.match_type string How the match was made: exact_name, exact_alias, exact_alias_pinned (alias that also pins a line of business), or id.
resolved.payer.confidence number Match confidence, 0.0–1.0 (1.0 exact name, 0.98 curated alias).
resolved.payer.resolved_plan_type string Present only when the matched alias pins a line of business — the line the criteria are filed under.
resolved.payer.mco_fallback boolean True when a Medicaid managed-care plan name resolved to the state Medicaid program that governs it.
resolved.payer.resolves_to_state_medicaid string Present only when mco_fallback is true — the state Medicaid payer the plan resolved to.
resolved.drug.id integer Stable drug id — reusable as drug_id in later requests.
resolved.drug.brand_name string Brand name (e.g. Wegovy).
resolved.drug.generic_name string Generic name (e.g. semaglutide).
coverage object[] One entry per plan type (or only the requested one). All paths below are relative to one entry.

Coverage entries (coverage[])

Field Type Description
plan_type string Plan type this entry answers for.
formulary string | null Formulary the answer is based on (the payer's default when coverage varies).
formulary_varies boolean True when the payer's formularies disagree for this combination — verify the member's specific formulary.
coverage_state string The verdict — one of the seven states above.
is_covered boolean Authoritative coverage flag for this drug × indication × plan type.
is_preferred boolean | null Whether the drug is a preferred agent on this formulary; null when the policy doesn't state a tier.
coverage_scope string standard, rider_required, or rider_excluded — whether coverage depends on the member's pharmacy-benefit design.
coverage_scope_note string | null Policy-sourced explanation of the benefit-design condition, when one applies.
basis string | null Stated policy basis for the determination, when the source provides one.

Requirements — demographics & labs

Field Type Description
requirements.age.min integer | null Minimum patient age in years.
requirements.age.max integer | null Maximum patient age in years.
requirements.bmi.min number | null Minimum BMI (kg/m²) without a qualifying comorbidity.
requirements.bmi.min_with_comorbidity number | null Lower BMI threshold (kg/m²) that applies with at least one accepted comorbidity.
requirements.bmi.min_asian number | null Alternate minimum BMI (kg/m²) for patients of Asian descent, when defined.
requirements.bmi.percentile_min integer | null Minimum BMI percentile for pediatric patients, when defined.
requirements.a1c.min number | null Minimum hemoglobin A1C in percent (e.g. 6.5 confirms a T2DM diagnosis).
requirements.a1c.max number | null Maximum hemoglobin A1C in percent, when the policy caps eligibility.
requirements.a1c.for_combination_therapy number | null A1C threshold that applies specifically when the drug is added to existing therapy.

Requirements — step therapy

Field Type Description
requirements.step_therapy.requires_metformin_trial boolean Whether a prior metformin trial is required before approval.
requirements.step_therapy.metformin_trial_duration_days integer | null Required length of the metformin trial in days.
requirements.step_therapy.metformin_exception_conditions string[] Conditions that waive the metformin requirement (e.g. intolerance, contraindication, ASCVD, CKD).
requirements.step_therapy.requires_prior_glp1_trial boolean Whether a trial of another GLP-1 agent is required first.
requirements.step_therapy.prior_glp1_drugs string[] GLP-1 agents that satisfy the prior-trial requirement.
requirements.step_therapy.prior_glp1_count_required integer | null Number of distinct prior GLP-1 trials required.
requirements.step_therapy.prior_weight_loss_drugs string[] Non-GLP-1 weight-loss agents that must be tried first (e.g. phentermine, Qsymia, Contrave).
requirements.step_therapy.prior_weight_loss_trial_months integer | null Required duration of each prior weight-loss-agent trial in months.

Requirements — condition-specific

Field Type Description
requirements.cardiovascular.requires_cv_disease boolean Whether established cardiovascular disease is required to qualify.
requirements.cardiovascular.cv_qualifying_events string[] CV events or diagnoses the payer accepts as qualifying (e.g. MI, stroke, PAD).
requirements.cardiovascular.requires_gdmt boolean Whether concurrent guideline-directed medical therapy is required.
requirements.cardiovascular.gdmt_medications string[] GDMT therapies the patient must be taking concurrently.
requirements.osa.requires_osa_diagnosis boolean Whether an obstructive sleep apnea diagnosis is required.
requirements.osa.ahi_min integer | null Minimum apnea-hypopnea index (events/hour) to qualify.
requirements.osa.requires_pap_trial boolean Whether a positive-airway-pressure (CPAP/BiPAP) trial is required first.
requirements.mash.requires_mash_diagnosis boolean Whether a MASH diagnosis is required.
requirements.mash.fibrosis_stage_min string | null Minimum liver fibrosis stage (e.g. F2) to qualify.
requirements.mash.fibrosis_stage_max string | null Maximum liver fibrosis stage (e.g. F3) covered for MASH.
requirements.mash.confirmation_methods string[] Accepted methods of confirming the MASH diagnosis (e.g. biopsy, imaging).
requirements.renal.egfr_min integer | null Minimum estimated glomerular filtration rate (mL/min/1.73m²).
requirements.renal.egfr_max integer | null Maximum eGFR (mL/min/1.73m²), used to define CKD eligibility windows.
requirements.renal.uacr_min integer | null Minimum urine albumin-to-creatinine ratio (mg/g).
requirements.lifestyle.requires_program boolean Whether a documented diet-and-exercise / lifestyle program is required.
requirements.lifestyle.duration_months integer | null Required length of the lifestyle program in months.

Requirements — diagnosis & exclusions

Field Type Description
requirements.diagnosis.requires_diagnosis_code boolean Whether a specific diagnosis code must accompany the submission.
requirements.diagnosis.codes string[] Accepted diagnosis codes (ICD-10), when the policy enumerates them.
requirements.diagnosis.confirmation_methods string[] How the diagnosis must be confirmed (e.g. clinical_diagnosis, lab_confirmation).
requirements.diagnosis.requires_lab_verification boolean Whether lab results documenting eligibility must be submitted.
requirements.diagnosis.excludes_diabetes boolean Whether a diabetes diagnosis disqualifies the patient under this indication (e.g. MACE-only criteria).
requirements.comorbidities_accepted string[] Weight-related comorbidities the payer accepts alongside the lower BMI threshold (e.g. HTN, dyslipidemia, T2DM).
requirements.exclusions.other string[] Policy-specific exclusions, verbatim from the source document.
requirements.exclusions.pregnancy boolean Whether pregnancy is a stated exclusion.
requirements.exclusions.type_1_diabetes boolean Whether type 1 diabetes is a stated exclusion.
requirements.exclusions.bariatric_surgery boolean Whether prior or planned bariatric surgery is a stated exclusion.

Pathways, documentation & quantity limits

Field Type Description
qualification_pathways object[] Distinct routes to approval. A patient qualifies via any single pathway by meeting all of its all_of conditions plus at least one any_of condition.
qualification_pathways[].pathway_name string Short label for the pathway (e.g. "Continuation of therapy").
qualification_pathways[].all_of string[] Conditions that must ALL be met under this pathway.
qualification_pathways[].any_of string[] Conditions of which AT LEAST ONE must be met. Empty when the pathway has no alternative branch.
required_documentation string[] Documentation the payer requires with the prior-authorization submission.
quantity_limits object[] Dispensing limits per strength grouping. Empty when the policy sets none.
quantity_limits[].strengths string[] Drug strengths the limit applies to ("all strengths" when uniform).
quantity_limits[].supply_28_day string | null Maximum quantity per 28-day supply, verbatim from the policy.
quantity_limits[].supply_84_day string | null Maximum quantity per 84-day (90-day-class) supply, when defined.

Approval durations

Field Type Description
approval.initial_months integer | null Length of the initial authorization in months.
approval.continuation_months integer | null Length of each renewal authorization in months.
approval.continuation_clinical_benefit string | null What the payer requires as demonstrated clinical benefit at renewal, verbatim from the policy.
approval.continuation_weight_loss_percent number | null Minimum percent weight loss from baseline that must be maintained for renewal.
approval.minimum_maintenance_dose_mg number | null Minimum maintenance dose in mg the patient must be on (e.g. 2.4 for Wegovy MACE criteria).
approval.minimum_therapy_weeks integer | null Minimum weeks on therapy before a continuation request is considered.

Provenance

Field Type Description
provenance.source_type string How the record was produced. Criteria detail is only returned for reviewed_policy — records a human reviewer confirmed against the source policy.
provenance.documented boolean Whether a source policy document or URL is on file for this record.
provenance.effective_date string | null Date the source policy took effect (YYYY-MM-DD).
provenance.expiration_date string | null Stated expiration or review date of the source policy, when published.
provenance.last_verified_at string | null Timestamp of the most recent human verification against the source policy (ISO 8601, UTC).

Null-valued fields in resolved.payer (resolved_plan_type, resolves_to_state_medicaid) are omitted from the JSON rather than sent as null.

Errors

Errors return a JSON body with a single human-readable error message.

Status Meaning
200 Success — including explicit no_data / no_match results.
400 Invalid request: unknown indication or plan_type, an unexpected body field (deny-by-default), or any query-string parameter.
401 Missing or invalid API key.
404 The payer or drug could not be resolved.
409 Requested plan_type contradicts the line of business pinned by the resolved payer alias.
429 Daily request limit reached for this API key.

OpenAPI specification

The complete schema — both endpoints, every field, type, enum, and the three verbatim example responses — is published as an OpenAPI 3.0 document. Use it to generate clients or import into your tooling.

Browse the rendered reference Download openapi.yaml

Get an API key

Access is provisioned per organization. Tell us what you're building and we'll follow up with credentials and a walkthrough of the data.

Request API access