Coverage & Prior Authorization

Cleo helps you with the entire prior authorization workflow—from checking if PA is required to generating appeal letters with verifiable citations from the patient’s records.

How It Works

Cleo has access to the CMS Medicare Part D formulary database—over 1.3 million drug entries across hundreds of insurance plans. When you ask about a medication, Cleo checks:

• Prior Authorization — Is PA required? What percentage of plans require it?
• Step Therapy — Must the patient try other medications first?
• Quantity Limits — Are there dispensing restrictions?
• Tier Level — Generic, preferred brand, specialty, etc.

Asking About Medications

In the Cleo side panel, you can ask questions like:

Question	What You’ll Learn
”Does Ozempic require prior auth?”	PA requirements across plans
”What tier is metformin?”	Formulary tier distribution
”Check coverage for Eliquis”	Full coverage summary
”Is step therapy required for Humira?”	Step therapy status

Tip

You can ask using either the brand name or generic name. Cleo understands both.

Understanding Results

When you ask about a medication, Cleo provides a summary like:

Formulary Coverage Summary (100 plans checked):

⚠️  Prior Authorization: REQUIRED in 85% of plans
✅ Step Therapy: Not required
📊 Quantity Limits: 4 pens per 28 days

Tier Distribution:
  Tier 3 (Preferred Brand): 15 plans
  Tier 5 (Specialty): 85 plans

Tier Levels Explained

Tier	Description	Typical Cost
Tier 1	Preferred Generic	Lowest copay
Tier 2	Generic	Low copay
Tier 3	Preferred Brand	Moderate copay
Tier 4	Non-Preferred	Higher copay
Tier 5	Specialty	Highest cost, often % coinsurance

Common Use Cases

New Prescription

Before prescribing a new medication, ask Cleo:

“Does [medication] require prior auth?”

This helps you anticipate insurance hurdles and discuss alternatives with the patient if needed.

Patient Questions

When a patient asks why their medication costs so much:

“What tier is [medication]?”

You can explain formulary placement and suggest lower-tier alternatives.

PA Planning

When you know PA will be required:

“What are the PA requirements for [medication]?”

Understand what documentation you’ll need to submit.

Generating PA Appeal Letters

When you need to submit a prior authorization, Cleo can search the patient’s records and generate a complete appeal letter with evidence.

What Cleo Searches

When you ask Cleo to generate a PA letter, it automatically searches:

• Medication history — Failed prior therapies, intolerance, adverse events
• Uploaded documents — Faxed records, referral letters, specialist notes
• Lab results — Supporting clinical evidence (A1c, eGFR, etc.)
• Conditions — Relevant diagnoses with ICD-10 codes

How to Generate a Letter

1. Navigate to the patient’s chart in your EHR

2. Ask Cleo to generate a PA letter:

   • “Generate a PA letter for Wegovy”
   • “Write prior auth appeal for Ozempic for weight management”
   • “Create PA letter for Humira”

3. Review the results — Cleo shows:

   • Evidence found (failed therapies, contraindications)
   • Supporting lab values
   • Missing evidence warnings

4. Open in Hub — Click the attachment card to open the full PA Letter Editor

The PA Letter Editor

After Cleo generates a letter, click “Open in Hub” to access the full editing experience:

Tab	What You Can Do
Evidence Review	Toggle evidence to include/exclude, verify citations
Edit Letter	Modify the summary, conclusion, and sections
Export	Copy to clipboard or export as PDF

Tip

Each piece of evidence includes a citation that links back to its source. Verify citations before submitting to ensure accuracy.

Example Output

When you ask for a PA letter, Cleo generates something like:

WEGOVY

PA Required: YES (85% of plans)
Step Therapy: Required

EVIDENCE FOUND (4):
  [!] Metformin (intolerance)
      "Discontinued due to severe GI distress..."
      Source: Epic - Primary Care, 2022-04-20

  [X] Phentermine (contraindication)
      "Stopped due to hypertension with BP >160/95..."
      Source: Weight Management Clinic, 2023-05-15

--- DRAFT LETTER GENERATED ---
Citations: 4

[Open in Hub to review and edit →]

Data Source

Coverage information comes from the CMS Medicare Part D formulary files, updated quarterly. This covers:

• All Medicare Part D plans
• RXCUI and NDC drug identifiers
• Prior authorization flags
• Step therapy requirements
• Quantity limit details
• Tier level assignments

Note

Currently, Cleo checks Medicare Part D formularies. Commercial insurance coverage may vary. Always verify with the specific insurer for non-Medicare patients.

Limitations

• Medicare Part D only — Commercial and Medicaid plans not yet included
• Formulary data — Shows if PA is required, not the specific approval criteria
• Quarterly updates — Data refreshed each quarter when CMS releases new files
• Evidence quality — Letter quality depends on available patient records

For specific PA approval criteria (diagnosis requirements, prior medications tried, etc.), you may still need to check the payer’s clinical policy bulletins.