Continuation criteria are what your plan checks when your authorization comes up for renewal. Instead of asking whether you qualified, it asks whether the drug worked. Most policies want a documented weight change from baseline, measured in clinic, and the specific threshold varies by plan.
This is one part of getting a GLP-1 covered. For the full picture, see GLP-1 Insurance Coverage: The Complete Guide.
What changes at renewal
Initial approval was about eligibility: your BMI, your comorbidities, your documented prior attempts. Renewal is about response. The plan has now paid for a course of treatment and wants evidence it produced something.
That shift catches people who assume renewal is a formality. It is a fresh review against different criteria, and it can be refused even when nothing about your situation has changed.
What the plan looks at
Most continuation criteria combine some of the following. Read your plan’s clinical policy for the exact set and the threshold it applies.
- Weight change from baseline, measured at a clinical visit. The comparison point is your documented starting weight, which is why that baseline needs to be right.
- Continued adherence, sometimes evidenced through refill history.
- Tolerability, meaning you are not experiencing effects that would make continuing inappropriate.
- Ongoing lifestyle intervention, in some policies.
The baseline problem
If your recorded baseline was taken after you had already started losing weight, your measured progress will look smaller than it actually was. This is the most common reason a renewal fails on the numbers. Check which weight and which date your plan is using before you accept a refusal.
It happens easily. You lose some weight while waiting for the prior authorization to clear, the first in-clinic weight after approval becomes the reference point, and several pounds of genuine progress disappear from the record.
Build the evidence from day one
The single most useful habit is having your weight measured and recorded at every visit, rather than relying on one reading before and one after.
A series of dated clinical weights does three things: it establishes a clean baseline, it shows a trajectory rather than a single comparison, and it protects you if one measurement is unrepresentative.
Ask for measured weights specifically. A number you reported does not carry the same weight in a review.
If you are short of the threshold
Weight is not the only outcome that matters clinically, and some policies recognise that explicitly.
Improvements in blood pressure, A1c, lipid panels, sleep apnea severity or liver enzymes are real, documented benefits. If your prescriber can show them, that is a legitimate argument for continuation even where the scale has moved less than the policy anticipated.
Waist circumference and body composition changes are also worth documenting, particularly alongside resistance training, where the scale can understate what has happened.
A refused renewal carries the same appeal rights as any other denial, and the argument is strongest when it addresses the specific criterion cited.
What happens at maintenance
Once you reach a stable weight, continued loss is no longer the goal, and a policy written around ongoing loss fits awkwardly.
Have your prescriber frame the renewal around maintained benefit rather than further reduction: weight held below baseline, comorbidities improved or controlled, and the clinical rationale for continuing. Not every policy handles maintenance explicitly, so it is worth checking yours before you get there.
Build the evidence from the start by having weights measured at every visit, which is the same record your original request depended on. If the authorization lapses before the renewal lands, the gap has its own fix.
Frequently asked questions
What if I stopped for a while and lost momentum?
Document the gap and the reason, particularly if it was supply or coverage related rather than a choice. A gap the plan caused is a poor basis for the plan to refuse continuation.
Does my starting weight come from before or after the PA?
It should be your documented pre-treatment weight. If a later weight is being used, raise it explicitly, because it changes the calculation.
How often do renewals come up?
Authorization periods vary by plan. Your approval letter states the end date.
Does switching drugs reset the baseline?
Often the plan treats a new drug as a new request with its own baseline. Confirm before switching, since it can affect how your progress is assessed.
Can I be denied if the drug is working?
Yes, if the documentation does not show it. Working and documented as working are different things, and the second is what gets reviewed.
What if my weight loss stalled but my labs improved?
That is worth putting in front of the reviewer. Ask your prescriber to include the lab changes in the continuation request rather than submitting weight alone.