What does a payer want to see before approving dulaglutide?

The pharmacy is accredited and I have verified that on the accreditor register.

This is a procedural question rather than a theoretical one, and I would like the procedure rather than the theory.

What I have done so far is read the label documentation where it exists and the two pharmacopoeial monographs that are publicly available, which cover the licensed presentation and say nothing about a research one.

What would you do, and what would you check afterwards?

Answering this needs the plan, since criteria vary and a general answer is not actionable.

Submit the supporting documents with the request rather than waiting to be asked. Requests denied for insufficient information are denials that a complete submission would have avoided.

Where prerequisite therapy is required, the record needs the agent, the dates, the dose and the reason it was stopped. "Tried and failed" without those four elements is not documentation.

Peer-to-peer review is a standard step in utilisation-management processes and resolves a meaningful share of disputes.

The denial reason is the appeal specification. Address it directly.

edited 12 Mar 2025 by jana_horakova — clarified the distinction between purity and content

Start by obtaining the criteria before the request is submitted, because a request written blind is a request written badly.

Each criterion must be evidenced in the clinical record, dated, before the request. A criterion asserted in a covering letter but absent from the notes is the commonest reason for a denial.

Specifically, approvals expire. Note the renewal date when the approval arrives, because a lapse mid-treatment is administratively identical to a fresh denial.

Research-use compounds are outside this framework entirely and are not approved for human use.

Evidence every criterion in the dated record, not in a covering letter.

Peer-to-peer review is available in many systems and is underused.

Obtain the medical policy for the specific drug and plan first. It lists the required diagnosis codes, thresholds, documented durations and any prerequisite therapy, and it is the checklist the reviewer works from.

Appeal windows and renewal periods are defined in plan documents and are strictly applied.

The caveat is that this is administrative navigation and nothing here is clinical or legal advice.

Get the criteria first. A request written blind is a request written badly.

The denial letter states the reason. That reason is the specification for the appeal.

Track the deadlines. Appeal windows are finite, and a well-founded appeal filed late is worth nothing at all.

Medical policies stating prior-authorisation criteria are published by plans and are obtainable before submission.

Processes differ by jurisdiction and by plan, so any general description will be wrong somewhere.

Attach everything on the first submission. Incomplete is the commonest denial.