In a GLP-1 program, the medical director’s duties come down to three written controls. A chart review plan that meets the minimum in each state where you have patients. A titration protocol, built from the FDA label, that tells every prescriber when to step up, hold or step down. And a refill gate that no fill passes until a clinician has reviewed the patient’s current status. Each one needs a signature and a record.
Launching the business, from licensure to sourcing, is covered in how to start a GLP-1 telehealth business. This post covers what the physician does after launch, every week.
The three duties at a glance
| Duty | What it controls | What sets the floor |
|---|---|---|
| Chart review | Whether prescribing across the panel is sound | State supervision and collaboration rules, which differ by state and by license type |
| Titration protocol | Dose steps, holds, step-downs and restarts | The FDA-approved label, then the physician’s written protocol |
| Refill gate | Whether the next fill goes out | State pharmacy refill limits as the outer edge, your clinical criteria as the working rule |
Chart review: the state sets a minimum and you set the sample
Two state rules for nurse practitioner prescribing show how far apart chart review requirements can sit.
In Texas, an APRN’s prescriptive authority agreement must describe a quality assurance and improvement plan that includes “chart review, with the number of charts to be reviewed determined by the APRN and physician” [22 Tex. Admin. Code § 222.5]. The same rule requires periodic meetings between the APRN and the physician that are documented and “take place at least once a month in a manner determined by the physician and the APRN” [22 Tex. Admin. Code § 222.5]. Texas leaves the sample size to the two of you. Pick a number you can meet every month, and record each review.
Tennessee sets the number for you. Under its rule for physicians supervising certified nurse practitioners, “a supervising physician shall personally review at least twenty percent (20%) of charts monitored or written by the certified nurse practitioner every thirty (30) days” [Tenn. Comp. R. & Regs. 0880-06-.02]. The same rule calls for the supervising physician’s personal review of a patient’s historical, physical and therapeutic data when prescriptions written by the certified nurse practitioner “fall outside the protocols” [Tenn. Comp. R. & Regs. 0880-06-.02]. In a GLP-1 program, an off-protocol dose is that trigger.
These are two examples of the range. Check the rule in each state where you have patients, for each license type you use. For how the supervising and collaborating roles differ from the medical director role, see medical director vs. supervising vs. collaborating physician.
What the chart has to show
A review only works if the chart holds what a reviewer needs. Florida’s standard is a useful model. A Florida physician’s record must contain enough information to “support the diagnosis, justify the treatment and document the course and results of treatment accurately,” including histories, examination results, test results and “records of drugs prescribed, dispensed, or administered” [Fla. Admin. Code R. 64B8-9.003]. If you give compounded injections in the office, Florida requires the record to show, at a minimum, items including the name and concentration, the lot number, the expiration date and the name of the compounding pharmacy or manufacturer [Fla. Admin. Code R. 64B8-9.003]. Florida also requires a physician records owner to keep records “for a period of at least five years from the last patient contact” [Fla. Admin. Code R. 64B8-10.002].
Use this checklist when you pull a GLP-1 chart:
- [ ] Baseline weight, BMI and the indication the prescriber documented
- [ ] Screening for a personal or family history of medullary thyroid carcinoma (MTC) or MEN 2, which the label lists as a contraindication [Wegovy prescribing information]
- [ ] Current diabetes medications, with any insulin or insulin secretagogue flagged
- [ ] Pregnancy status and plans, and contraception where relevant
- [ ] Each dose step, with its date and the reason for stepping up, holding or reducing
- [ ] Check-ins between steps, including GI tolerance and abdominal pain
- [ ] For compounded product, the concentration on the pharmacy label and the dose in both milligrams and volume
- [ ] The clinician who approved each fill, and the date
The titration protocol starts from the label
For approved products, the label gives you the skeleton. Wegovy injection starts at 0.25 mg once weekly for 4 weeks, then escalates, “titrating every 4 weeks to achieve the maintenance dosage” [Wegovy prescribing information]. If a patient does not tolerate a dose during escalation, the label says to “consider delaying dosage escalation for 4 weeks” [Wegovy prescribing information]. Zepbound starts at 2.5 mg once weekly for 4 weeks, and the label says to “increase the dosage in 2.5 mg increments after at least 4 weeks” until the maintenance dose is reached, with 15 mg once weekly as the maximum for all indications [Zepbound prescribing information].
Missed doses belong in the protocol too, and the two labels handle them differently. For Wegovy injection, “If 2 or more consecutive doses of WEGOVY injection are missed, reinitiate dosage escalation at a lower dosage” [Wegovy prescribing information]. For Zepbound, the patient takes a missed dose within 4 days (96 hours); after that, the patient skips it and resumes on the regular day [Zepbound prescribing information]. A protocol that tells a semaglutide patient to restart at the last dose after a three-week gap contradicts the label.
Compounded product needs more care. FDA states that compounded drugs are not FDA-approved, which means “FDA does not verify the safety, effectiveness or quality of compounded drugs before they are marketed” [FDA, compounding questions and answers]. FDA has received adverse event reports, some requiring hospitalization, that may be related to dosing errors with compounded injectable semaglutide, including patients measuring incorrect doses “and in some cases, health care professionals miscalculating doses of the drug” [FDA, concerns with unapproved GLP-1 drugs]. FDA has also received reports that may be related to compounded semaglutide or tirzepatide prescribed “in doses beyond what is in the FDA-approved drug label” [FDA, concerns with unapproved GLP-1 drugs].
So write every compounded step twice: in milligrams, and as the volume to draw at the concentration printed on that pharmacy’s label. Keep the steps and the ceiling inside the approved label for the same molecule. When the pharmacy or the concentration changes, reissue the protocol before the next fill.
Where a state requires a written protocol for a nurse practitioner, the titration protocol belongs inside it. In Florida, an APRN performs authorized functions “within the framework of an established protocol that must be maintained on site” at the locations where the APRN practices, unless the APRN is registered and practicing under s. 464.0123 [Fla. Stat. § 464.012]. Tennessee’s rule requires the supervising physician to “develop clinical guidelines in collaboration with the certified nurse practitioner” [Tenn. Comp. R. & Regs. 0880-06-.02].
A titration decision sequence
- Confirm the patient took each dose at the current step for at least 4 weeks. If doses were missed, apply the label’s missed-dose rule first.
- Review the check-in for GI tolerance, abdominal pain and fluid intake.
- If the patient is not tolerating the current dose, hold the step. For Wegovy, the label allows a 4-week delay in escalation [Wegovy prescribing information].
- If pancreatitis is suspected, stop. The Wegovy label says “Discontinue if pancreatitis is suspected” [Wegovy prescribing information]. If cholelithiasis is suspected, the label says “gallbladder studies and clinical follow-up are indicated” [Wegovy prescribing information].
- If the patient takes insulin or an insulin secretagogue, review glucose and that medication before stepping up. The label says reducing its dose “may be necessary” [Wegovy prescribing information].
- If response and tolerance are adequate at a maintenance dose, stay there. Zepbound’s label says to “consider treatment response and tolerability when selecting the maintenance dosage” [Zepbound prescribing information].
- Document the decision, the dose in milligrams and volume, and the clinician who made it.
The refill gate decides whether the next fill goes out
State pharmacy law sets an outer edge, and it is wide. Under the Texas rule for community pharmacies, prescription drug orders for dangerous drugs “may not be refilled after one year from the date of issuance of the original prescription drug order” [22 Tex. Admin. Code § 291.34]. That is a pharmacy ceiling. Your clinical gate should sit well inside it.
At MDside, each fill of a compounded GLP-1 is a new prescription, issued for a 56-day cycle and only after a clinician reviews the patient’s check-in. The cycle length follows the beyond-use date, explained in why a telehealth GLP-1 prescription runs 56 days. The gate itself is this checklist:
- [ ] A check-in completed since the last fill, with current weight, current dose and doses missed
- [ ] No new red flags: severe or persistent abdominal pain, vomiting, signs of gallbladder disease
- [ ] Pregnancy status reviewed against the label (see below)
- [ ] Medication list unchanged, or the change reviewed by a clinician
- [ ] The dose on the new prescription matches the titration protocol
- [ ] For compounded product, a documented clinical reason for compounded over approved product
Pregnancy is where the two labels give the most specific instructions. For patients taking Wegovy for weight reduction, the label says to discontinue “at least 2 months before a planned pregnancy because of the long half-life of semaglutide” [Wegovy prescribing information]. The Zepbound label says “When pregnancy is recognized, discontinue ZEPBOUND,” and advises females using oral contraceptives to switch to a non-oral method or add a barrier method “for 4 weeks after initiation and for 4 weeks after each dose escalation” [Zepbound prescribing information]. For Zepbound, each dose escalation therefore restarts a contraception window, and the refill gate is where you catch it.
The compounded-product reason belongs in the chart
The federal 503A exemption covers a drug product “compounded for an identified individual patient based on the receipt of a valid prescription order,” among other conditions [21 U.S.C. § 353a]. One condition is that the compounder does not compound “regularly or in inordinate amounts” drug products that are essentially copies of a commercially available drug product. The statute excludes from that term a change made for an identified patient “which produces for that patient a significant difference, as determined by the prescribing practitioner” [21 U.S.C. § 353a]. That determination belongs to the prescriber, so it belongs in the chart. FDA’s own recommendation is that “Compounded drugs should only be used in patients whose medical needs cannot be met by an FDA-approved drug” [FDA, concerns with unapproved GLP-1 drugs].
As of November 2026, FDA’s compounding policy page records a February 21, 2025 update in which FDA determined the semaglutide injection shortage resolved. It also states that for a state-licensed pharmacy or physician compounding semaglutide injection products under section 503A, the period of enforcement discretion has ended [FDA, GLP-1 compounding policy update]. For what changed for compounders, see compounded GLP-1s after the shortage.
Where MDside differs
A shortcut we see in the market is to authorize a year of refills at the first visit and review charts only after a complaint. MDside does not work that way. The physician-owned PC holds clinical authority. The physician signs the chart review plan, the titration protocol and the refill gate, and the MSO’s platform enforces them without the power to change them. No fill goes out without a clinician’s review. When a pharmacy or concentration changes, the protocol is reissued before the next prescription. That is what a medical director is for in a GLP-1 program, and it is how our weight management service runs.
What this means for you
Pull your current GLP-1 documents and check that all three exist in writing: a chart review plan with a number and a schedule, a titration protocol that matches the label’s steps and missed-dose rules, and a refill gate with named criteria. Then confirm the chart review numbers against the rules in each state where you have patients and each license type you use. If you use compounded product, add the volume-to-draw column and the clinical reason to every chart. Finally, make sure your medical director signs each document and can show the review trail on request.
References
- 22 Tex. Admin. Code § 222.5, Prescriptive Authority Agreement. Texas Board of Nursing, via Cornell LII, current quarterly copy as of November 2026. Link
- Tenn. Comp. R. & Regs. 0880-06-.02. Tennessee Board of Medical Examiners, via Cornell LII, last amended effective August 22, 2004. Link
- Fla. Admin. Code R. 64B8-9.003, Standards for Adequacy of Medical Records. Florida Board of Medicine, via Cornell LII, effective September 9, 2013. Link
- Fla. Admin. Code R. 64B8-10.002. Florida Board of Medicine, via Cornell LII, current copy as of November 2026. Link
- Fla. Stat. § 464.012. Florida Legislature, 2025 Florida Statutes. Link
- 22 Tex. Admin. Code § 291.34, Records (Class A pharmacies). Texas State Board of Pharmacy, via Cornell LII, current copy as of November 2026. Link
- 21 U.S.C. § 353a, Pharmacy compounding. U.S. Government Publishing Office, 2023 edition of the U.S. Code. Link
- Wegovy prescribing information. DailyMed, National Library of Medicine, label revised June 2026. Link
- Zepbound prescribing information. DailyMed, National Library of Medicine, label revised August 2026. Link
- FDA, concerns with unapproved GLP-1 drugs. U.S. Food and Drug Administration, accessed November 2026. Link
- FDA, compounding questions and answers. U.S. Food and Drug Administration, accessed November 2026. Link
- FDA, GLP-1 compounding policy update. U.S. Food and Drug Administration, accessed November 2026. Link
Frequently asked questions
How often does a medical director need to review GLP-1 charts?
It depends on the state and the prescriber’s license. In Texas, the APRN and physician set the number of charts in the prescriptive authority agreement and must meet at least once a month. In Tennessee, a supervising physician personally reviews at least 20 percent of a certified nurse practitioner’s charts every 30 days. Check each state where you have patients.
What should a GLP-1 titration protocol include?
Start from the FDA label: the starting dose, the 4-week steps, the maintenance range and the maximum. Add the label’s missed-dose rules, criteria for holding or reducing a step, and stop rules such as suspected pancreatitis. For compounded product, write each step in milligrams and in volume at the pharmacy’s concentration, and reissue the protocol when that concentration changes.
Can a GLP-1 prescription be refilled without a new visit?
Pharmacy rules can allow refills. In Texas, community pharmacy rules bar refilling a dangerous drug prescription after one year from the date it was issued. That is an outer limit. MDside issues each compounded GLP-1 fill as a new 56-day prescription, and only after a clinician reviews the patient’s check-in, weight, dose, symptoms, medications and pregnancy status.
Why does the chart need a reason for using compounded semaglutide?
Section 503A exempts a drug compounded for an identified patient on a valid prescription from certain federal requirements if its conditions are met. One condition bars compounding copies of commercially available products regularly or in inordinate amounts. A change that produces a significant difference for the patient, as determined by the prescribing practitioner, falls outside that limit. Record the prescriber’s reason in the chart.
This is general information, not legal advice. Rules vary by state and change. Confirm your own facts with counsel.