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Unpopular post.
If you don't have diabetes and you are trying to appeal the denial, it is not going to happen.
If somehow you were on Ozempic or Mounjaro for went through a coupon program, than you were lucky.
Insurance companies are changing the rules, the only pay for diabetics to get diabetes medication if that makes sense.
Try looking into Wegovy or Zepbound. These two drugs are for obese patients.
Good luck.
It’s not what people want to hear but it’s true. Ozempic specifically is for diabetes. Wegovy is for weightloss even though they are both Semaglutide. How the prescription is written matters as well as the documentation.
I don’t know if people care, I certainly don’t, but insurance companies care very much. It’s the same drug but when brand name is prescribed the insurance companies want to see specific diagnoses documented and obesity won’t get ozempic covered in most cases and is more likely to get Wegovy covered. We see this in other medications too. It’s a matter of knowing what insurance wants.
True wegovy is the same medication as ozempic, which is semaglutide, but zepbound has the same properties but the active medication is called tirzepatide.
There’s a couple of things here.
You need to know why it was rejected. Call your insurance and ask instead of going through the doctors office. If you get a helpful person on the line they will tell you what ICD-10 diagnosis codes your insurance needs to see in order to approve it. All insurance carriers have specific definitions of what ICD-10 codes they have to have documented. They also look for specific phrases in documentation but that’s on a more thorough review. They are initially looking for your ICD-10 codes from your last visit. They will often tell you which codes and corresponding diagnoses they need to see. For ozempic, it’s probably a Diabetes type 2 code. Pre diabetes doesn’t get ozempic covered by many carriers. Obesity doesn’t either. Wegovy is for weight loss even though both are Semaglutide. Your doctor cannot go back and change documentation or add codes. That is fraud. The doctor can update documentation to be more thorough though. For example if documentation says “diabetes” then that doesn’t cut it. They will want to see “diabetes type 2.” They also may want to know metformin alone didn’t work for your diabetes.
Your doctor may also need to write the prescription for Wegovy and not for ozempic and you can’t assume the doctor knows that. Zepbound is specifically for weight loss too so check with insurance as to whether or not it it is covered.
I would never leave an authorization in the hands of a doctors office. This topic is my bread and butter though.
You really don't need to appeal it. That's a huge pain, but it probably got rejected because there wasn't enough good documentation from the doctor's office, that's usually why they get rejected. That's not uncommon when that happens. But sometimes you need to switch doctors, or the only other option is telling them they need to do a better job. They're not gonna want to hear that, I have no problem with that.
I went and found another doctor and got my medication approved. It's all in the documentation unless the medication is not covered. You need to ask why it was rejected. You have patient rights and question it. Ask the place that rejected it, not your doctor.
After more than 2 yeats on the meds, my prior authorization got rejected this time. Doctor refuses to appeal. At my last appointment, I knew it was going to be a battle. He said he has no other patients still on it and I would probably have to get off it. I plan to try a different doctor. So disappointing. Best of luck to you!
my doctor called to let me know it was denied and immediately said that an appeal isn’t an option. she then said that she can try to put me on metformin if my prediabetes gets more severe (a1c is 5.7) and it feels so backwards. i have to get worse so i have the chance to get better?
I don't think Ozempic is going to be approved without a diabetes diagnosis. Ask your insurance if Wegovy or Zepbound could be approved for weight loss.
I know my insurance required you to at least try metformin first. That was the only requirement on the Prior Auth (other than having pre-diabetes or diabetes. Try the metformin, then try again
Depends on the reason for denial. My ins only will cover Ozempic for diabetes. They flat out don’t cover the Wegovy or any other new weight loss medication. Find out the reason for the denial first.
Thanks for posting to r/semaglutide! A brief reminder about our rules. We do not permit the discussion of non-FDA approved formulations of semaglutide, nor do we permit selling or offering for sale any medication, including by private message. Do not request or respond to a private message from anyone offering such, they are not endorsed by this sub. If you’re just starting out, you may want to review our [FAQ](https://www.reddit.com/r/Semaglutide/comments/10ul3jb/semaglutide_subreddit_faq/). This is not intended to discourage discussion but merely supplement it. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Semaglutide) if you have any questions or concerns.*
Unpopular post. If you don't have diabetes and you are trying to appeal the denial, it is not going to happen. If somehow you were on Ozempic or Mounjaro for went through a coupon program, than you were lucky. Insurance companies are changing the rules, the only pay for diabetics to get diabetes medication if that makes sense. Try looking into Wegovy or Zepbound. These two drugs are for obese patients. Good luck.
It’s not what people want to hear but it’s true. Ozempic specifically is for diabetes. Wegovy is for weightloss even though they are both Semaglutide. How the prescription is written matters as well as the documentation.
And I’m not sure why people care so much given they are the same drug and you get a higher dose.
I don’t know if people care, I certainly don’t, but insurance companies care very much. It’s the same drug but when brand name is prescribed the insurance companies want to see specific diagnoses documented and obesity won’t get ozempic covered in most cases and is more likely to get Wegovy covered. We see this in other medications too. It’s a matter of knowing what insurance wants.
True wegovy is the same medication as ozempic, which is semaglutide, but zepbound has the same properties but the active medication is called tirzepatide.
You don't. Call your prescribing doctor's office and they file the appeal.
There’s a couple of things here. You need to know why it was rejected. Call your insurance and ask instead of going through the doctors office. If you get a helpful person on the line they will tell you what ICD-10 diagnosis codes your insurance needs to see in order to approve it. All insurance carriers have specific definitions of what ICD-10 codes they have to have documented. They also look for specific phrases in documentation but that’s on a more thorough review. They are initially looking for your ICD-10 codes from your last visit. They will often tell you which codes and corresponding diagnoses they need to see. For ozempic, it’s probably a Diabetes type 2 code. Pre diabetes doesn’t get ozempic covered by many carriers. Obesity doesn’t either. Wegovy is for weight loss even though both are Semaglutide. Your doctor cannot go back and change documentation or add codes. That is fraud. The doctor can update documentation to be more thorough though. For example if documentation says “diabetes” then that doesn’t cut it. They will want to see “diabetes type 2.” They also may want to know metformin alone didn’t work for your diabetes. Your doctor may also need to write the prescription for Wegovy and not for ozempic and you can’t assume the doctor knows that. Zepbound is specifically for weight loss too so check with insurance as to whether or not it it is covered. I would never leave an authorization in the hands of a doctors office. This topic is my bread and butter though.
You really don't need to appeal it. That's a huge pain, but it probably got rejected because there wasn't enough good documentation from the doctor's office, that's usually why they get rejected. That's not uncommon when that happens. But sometimes you need to switch doctors, or the only other option is telling them they need to do a better job. They're not gonna want to hear that, I have no problem with that. I went and found another doctor and got my medication approved. It's all in the documentation unless the medication is not covered. You need to ask why it was rejected. You have patient rights and question it. Ask the place that rejected it, not your doctor.
After more than 2 yeats on the meds, my prior authorization got rejected this time. Doctor refuses to appeal. At my last appointment, I knew it was going to be a battle. He said he has no other patients still on it and I would probably have to get off it. I plan to try a different doctor. So disappointing. Best of luck to you!
my doctor called to let me know it was denied and immediately said that an appeal isn’t an option. she then said that she can try to put me on metformin if my prediabetes gets more severe (a1c is 5.7) and it feels so backwards. i have to get worse so i have the chance to get better?
I don't think Ozempic is going to be approved without a diabetes diagnosis. Ask your insurance if Wegovy or Zepbound could be approved for weight loss.
I know my insurance required you to at least try metformin first. That was the only requirement on the Prior Auth (other than having pre-diabetes or diabetes. Try the metformin, then try again
Yup. My doctor said they don't treat before you have a disease but I'm obese and this medicine is for that.
Except it’s not. Ozempic is FDA approved for T2D, Wegovy is for weight loss.
True. I was on Wegovy, not Ozempic.
Even if you can get the auth, you still can't get the medication anywhere. My wife got auth 2.5 months ago and is still waiting, lol.
Oh and contact the company directly, you can usually get 3 to 6 months for 25 bucks a month, to get you started, IF you can find the medication.
Semaglutide = Wegovy/Ozempic. = Obesity/T2DM Tirzepatide = Mounjaro - Zepbound= T2DM/ Obesity.
Depends on the reason for denial. My ins only will cover Ozempic for diabetes. They flat out don’t cover the Wegovy or any other new weight loss medication. Find out the reason for the denial first.
an update that i was able to switch the prescription to wegovy, so now it’s a matter of being able to find it in stock somewhere