How YourMD Decides What to Prescribe

A lot happens between your intake submission and your prescription. A board-certified internist explains every step — the safety screens, contraindication hard blocks, physician review process, and when and why we say no.

A lot happens between the moment you submit your intake and the moment a prescription is sent to your pharmacy. Here is exactly what that process looks like — what your physician reviews, what triggers a pause or a refusal, and why the standards exist.

Step 1: Safety Screen Before Clinical Evaluation

Every YourMD intake begins with safety questions before clinical questions. These are not administrative — they are clinical triage. The intake asks about current chest pain, difficulty breathing, signs of stroke, hypertensive urgency above 180/120 mmHg with symptoms, and diabetic emergencies. If any safety screen returns a positive response, the intake does not continue to scheduling. It shows emergency guidance — call 911, go to the nearest emergency department — instead of a booking calendar. No visit fee is collected. This is not a conversion optimization decision. It is the appropriate clinical response to an acute presentation that telehealth cannot and should not manage.

Step 2: Contraindication Hard Blocks

Before a physician reviews any intake, the system runs automated contraindication checks. These are hard blocks that prevent prescribing regardless of patient request or physician discretion. Current hard blocks include:

GLP-1 medications: Personal or family history of medullary thyroid carcinoma or MEN2 — absolute FDA boxed warning contraindication
GLP-1 medications: Current Type 1 diabetes diagnosis
ACE inhibitors and ARBs: Current pregnancy — absolute teratogenic contraindication
Statins: Current pregnancy — Category X
Finasteride: Current pregnancy; also triggers warning for women of childbearing age not on reliable contraception
Sermorelin and GH-axis peptides: Active malignancy or cancer within past 5 years
Rapamycin: Active malignancy, pregnancy, active infection
Metformin: eGFR <30 — absolute renal contraindication
Sildenafil and tadalafil: Current nitrate use in any form — absolute cardiovascular contraindication
Bremelanotide (PT-141): Uncontrolled hypertension
ACE inhibitor + ARB combination: Never prescribed together

Hard blocks cannot be overridden by patient attestation, physician discretion, or any other pathway.

Step 3: Physician Clinical Review

After safety screening and contraindication checks, the intake is reviewed personally by Dr. Surapaneni. The review covers:

Medical history assessment

Every reported medical condition is assessed against the requested treatment. Some conditions are absolute contraindications (already blocked in Step 2). Others require clinical judgment — a patient with controlled hypertension requesting GLP-1 therapy is a different clinical picture than a patient with poorly controlled hypertension on four medications.

Medication review and interaction check

Every current medication is cross-referenced against the requested prescription. Interactions the physician is most alert to in the YourMD treatment mix: CYP3A4 inhibitors with rapamycin (can increase levels 5–10×), gemfibrozil with statins (dramatically increases myopathy risk), SGLT2 inhibitors with insulin in patients presenting as T2D (euglycemic DKA risk), and metformin with upcoming IV contrast procedures (hold protocol discussion required).

Lab requirements assessment

Several medications require lab results before prescribing:

ACE inhibitors and ARBs: Baseline BMP (creatinine, eGFR, potassium) required
Statins: Baseline lipid panel and liver function required
Metformin: eGFR required — contraindicated at eGFR <30, caution 30–45
High-dose Vitamin D3: Baseline 25-OH Vitamin D required
Sermorelin: Baseline IGF-1 required — titrates to physiological range, not fixed dose
Diabetes medications: Current A1C and eGFR required

If required labs are not available, the intake results in a lab order and a scheduled follow-up — not a prescription.

Scope of service assessment

Cases I refer out rather than prescribe for: new heart failure diagnosis (requires in-person cardiac evaluation including echocardiography), LDL-C above 250 mg/dL (likely familial hypercholesterolemia requiring lipidology evaluation), resistant hypertension on 3+ medications (secondary cause workup required), triglycerides ≥1,000 mg/dL (acute pancreatitis risk), suspected secondary hypertension causes (pheochromocytoma, primary aldosteronism, renal artery stenosis), and GLP-1 request with active pancreatitis history (requires specialist clearance first).

Step 4: The Prescribing Decision

After completing the above review, the physician reaches one of four outcomes:

Approve and prescribe: Prescription sent to pharmacy with visit summary in patient portal
Approve with modification: A different medication, dose, or formulation is more appropriate — prescribed with explanation of why
Conditional approval pending labs: Clinical case appropriate but required labs not yet available — lab order sent, follow-up scheduled, no additional visit fee
Decline with explanation: Outside scope, contraindicated, or clinically inappropriate — specific clinical explanation provided with guidance on where to get appropriate care. First-visit fee refunded if the decline is based on something the patient couldn't have known from the intake description alone

What We Will Never Do

Prescribe controlled substances of any schedule — no opioids, no benzodiazepines, no stimulants, no testosterone, no ketamine, no phentermine, no exceptions
Prescribe compounded semaglutide, tirzepatide, or any compounded GLP-1 medication
Approve a prescription without personally reviewing the intake
Override a contraindication hard block on the basis of patient assurance
Prescribe a medication requiring lab monitoring without first reviewing relevant labs
Use approval rate as a performance metric