Express Scripts denied pre-authorization for Ozempic. What to do now?

[Anonymous]

I am 50 pounds overweight and marginally pre-diabetic. DR put in a prescription for Ozempic but express scripts denied it. what can I do now?

[Anonymous]

Go to a real doctor?

[Anonymous]

What, pray tell, is “marginally pre-diabetic?”

If you want to lose 50, eat less and move more and cut down on carbs. That will do a lot to help your glucose too. You don’t need Ozempic.

[Anonymous]

Most if not all prescription plans have an appeal process. Your doctor might know or you can call Express Scripts and ask. Usually requires your doctor to fill out a form and mail it in. Likely your doctor will need to explain why other less expensive treatments (like lifestyle?) are not an option -- that you have tried these to no avail.

I have appealed script denials a few times and they usually go through if you take the time to do the paperwork.

[Anonymous]

thank you! I will look at the appeal process.

[Anonymous]

Ozempic has been a miracle for me, but in terms of insurance coverage you just have to call your insurance company aand see if there’s anything you can do but Ozempic probably won’t be covered for you.

[Anonymous]

Anonymous wrote:What, pray tell, is “marginally pre-diabetic?”

If you want to lose 50, eat less and move more and cut down on carbs. That will do a lot to help your glucose too. You don’t need Ozempic.

my A1c is outside the normal range, but only a little.

yes, I do need Ozempic. I have been on a diet for the past 40 years.

[Anonymous]

Anonymous wrote:thank you! I will look at the appeal process.

There is a protocol. You will need to try Metformin first for the diabetes. Ozempic is not indicated for weight loss so that’s not going to get the approval.

What, exactly, is “marginal pre-diabetes?”

[Anonymous]

Anonymous wrote:Ozempic has been a miracle for me, but in terms of insurance coverage you just have to call your insurance company aand see if there’s anything you can do but Ozempic probably won’t be covered for you.

it's covered but has this preauthorization process which I don't understand. it looks like some condition needs to be met for the coverage, but nobody stated what the condition is.

[Anonymous]

Anonymous wrote:

Anonymous wrote:thank you! I will look at the appeal process.

There is a protocol. You will need to try Metformin first for the diabetes. Ozempic is not indicated for weight loss so that’s not going to get the approval.

What, exactly, is “marginal pre-diabetes?”

how about wegovy?

[Anonymous]

Anonymous wrote:

Anonymous wrote:What, pray tell, is “marginally pre-diabetic?”

If you want to lose 50, eat less and move more and cut down on carbs. That will do a lot to help your glucose too. You don’t need Ozempic.

my A1c is outside the normal range, but only a little.

yes, I do need Ozempic. I have been on a diet for the past 40 years.

See an endocrinologist. Expect to spend six months on Metformin first and be told to lose 20 before they will consider putting you on a medication that costs thousands

[Anonymous]

Anonymous wrote:Go to a real doctor?

I have been to two "real doctors". one prescribed ozempic and the other wegovy. thank you for your concern.

[Anonymous]

Anonymous wrote:

Anonymous wrote:Ozempic has been a miracle for me, but in terms of insurance coverage you just have to call your insurance company aand see if there’s anything you can do but Ozempic probably won’t be covered for you.

it's covered but has this preauthorization process which I don't understand. it looks like some condition needs to be met for the coverage, but nobody stated what the condition is.

It probably is trying Metformin first

[Anonymous]

What's the insurance plan? If military/retired, you have to try the "other" meds and prove they're not effective first. I know metformin is one, but I do not not the others.

[Anonymous]

it's a private insurance through employer (Cigna + express scripts).