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

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

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[quote=Anonymous][quote=Anonymous][quote=Anonymous][quote=Anonymous]If you bothered to read the requirements for Cigna that someone else posted, you will see you will be required to lose at least 5% of your body weight prior to being given Wegovy.

Maybe this is why OP is gunning so hard for  Ozempic on the “marginal pre-diabetes” argument (which won’t fly)..

Bottom line is you won’t just be issued these drugs. One way or another there are intermittent steps — metformin for a diabetes diagnosis and if that doesn’t improve A1C, you get Ozempic, but that is at least three months away.

[b]For Wegovy, you have to lose at least 5% of your body weight before they will approve it.[/b] This is to demonstrate a commitment to what it will take to sustain any weight loss since you will only be approved for the it for between 5 months and one year,

So if you are 200 pounds, get that documented and work to lose at least 10. That will also take you about two-three months. Then you might get the meds.[/quote]

where did you read this?[/quote]

Read the FDA indications on p. 2 of this link someone else provided on the second page of the thread.

https://static.cigna.com/assets/chcp/pdf/coveragePolicies/cnf/cnf_684_coveragepositioncriteria_weight_loss_glp1_agonists_pa.pdf

You could have read this earlier but instead kept carrying on like you’re some entitled victim here. I read it. So can you. Just like I can lose weight but eating less and moving more and so can you.

I lose 50 pounds on my own before I started Ozempic. Interestingly haven’t lost a pound since.

I had an A1C of 10 though.[/quote]

I’m the one that posted the Cigna requirements.  I’ve been on Wegovy for about 20 mo.

The 5% loss that you are reading falls under Continuing Therapy not Initial Therapy.  Continuing Therapy is when you go for your 2nd PA.  They are looking to validate that Wegovy is working for you.  You have to show that you have lost 5% of you weight from your initial starting weight prior to starting Wegovy.  At a certain point, you will no longer continue to lose weight.  The medication is a lifetime medication so to continue receiving it with insurance converge you show that it worked.

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