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What are the Ozempic prior authorization criteria for weight loss?

Written by Klarity Editorial Team

Published: Jun 3, 2024

Medically Reviewed by Klarity Editorial Team

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Ozempic is helping people — a lot of them in Hollywood — lose weight. Can it help you too? If you can get a prescription, it can. But if you want insurance to pay for it, you may need prior authorization and you need to know the Ozempic prior authorization criteria for weight loss. 

In this article, learn about the Ozempic prior authorization criteria for weight loss, including what prior authorization is, how to get it, and what to do if you’re denied.

Considering Ozempic or another medication for weight loss? Find a weight loss provider on Klarity who can evaluate your specific needs and goals, and prescribe Ozempic or another weight loss medication if needed.

Get a prescription for Ozempic in as little as 24 hours.

Understanding prior authorization and why you need it for Ozempic (semaglutide)

Prior authorization is a process health insurance companies use to make sure prescribed medications and treatments are medically necessary and to lower their costs. Newer or more expensive medications, like Ozempic, often require prior authorization approval before insurance covers them. To get approved, your healthcare provider submits paperwork justifying that the prescribed medication or treatment is medically necessary for you. A reviewer then approves or denies based on medical necessity in your case. 

You likely need prior authorization to get Ozempic with insurance. Ask your provider or call the customer service number on the back of your insurance ID card to find out. 

So, what will your insurance company consider when deciding to approve or deny your PA? 

The Ozempic prior authorization criteria for weight loss

To get prior authorization for Ozempic, you most likely need to meet the U.S. Food and Drug Administration (FDA)-approved criteria for use. 

Ozempic is approved to lower blood sugar in adults with type 2 diabetes alongside diet and exercise. It also reduces the risk of a major cardiovascular event, such as heart attack or stroke, in adults with type 2 diabetes and known heart disease. This means that if you have type 2 diabetes and are struggling to control your blood sugar, and you’re prescribed Ozempic, you’re likely to get prior authorization approved. 

Because weight loss is an off-label use, there aren’t any real Ozempic prior authorization criteria for weight loss. Your healthcare provider can prescribe Ozempic off-label if they feel it’s safe and effective for you. Be aware that if you’re taking Ozempic for weight loss without type 2 diabetes, your insurance company will most likely deny your prior authorization. That doesn’t mean you can’t still try to get it approved if it’s medically necessary for you. 

Whether you meet the criteria perfectly, here’s what you need to know about the prior authorization process.

How to get prior authorization for Ozempic in 4 steps 

Follow these steps to get prior authorization for Ozempic.

Step 1: Have your weight loss needs evaluated and get a prescription

To get prior authorization for Ozempic, you need a valid prescription from a licensed healthcare professional. You can find an online weight loss provider on marketplace services, like Klarity.  Your provider will evaluate your weight loss needs and goals. They can prescribe Ozempic for weight loss if it’s appropriate and safe for you. 

Step 2: Submit a prior authorization request for Ozempic

If your insurance company requires prior authorization for Ozempic, your healthcare provider will submit a request. This involves sharing your detailed medical history, including current conditions and medications you’ve already tried. It’s likely your provider’s office already has a process in place for requesting prior authorization. 

Step 3: Follow up on the decision

Prior authorization approvals can be granted in minutes or take several days to weeks. It depends on whether the review process is automated or requires human attention. Regardless, you don’t have to wait to hear. You can, and should, call your insurance company to check the status of your approval.

Step 4: Start on Ozempic if you’re approved

You can start taking your medication once you receive approval. Fill your prescription at your pharmacy and take the medication as prescribed. 

What to do if your prior authorization for Ozempic is denied

If your insurance company denies your prior authorization for Ozempic, it doesn’t mean you can’t get coverage. You have the right to appeal and, according to Reddit users who take Ozempic, you may have to appeal or request new prior authorization multiple times. 

Insurance companies maintain their own Ozempic prior authorization criteria, beyond the FDA-approved prescribing criteria. This may include factors like maintaining certain A1C levels. If, at any point, you don’t meet your insurer’s criteria, they can deny prior authorization, and even revoke existing authorizations. If this happens to you, you can appeal or submit a new prior authorization request with the help of your healthcare provider. 

How to appeal a prior authorization denial for Ozempic

To appeal a prior authorization denial for Ozempic, it’s important to find out why you were denied. Your insurer is required to disclose this information and provide an opportunity for your healthcare provider to talk to the reviewer. Sometimes, prior authorization requests are denied due to administrative or clerical errors. These decisions are often easily overturned by submitting additional or corrected information. If this isn’t the case, continue with the appeals process. 

Most states have 3 levels of appeals.

  • First-level appeals involve a phone call to your insurance company asking for reconsideration. This is what you do to address denials due to administrative or clerical errors. 
  • Second-level appeals involve review by a medical director at your insurance company. The point is to prove that your request should be accepted within your plan’s coverage guidelines. 
  • Third-level appeals, or external reviews, happen when a licensed healthcare professional and an independent reviewer at your insurance company evaluate your request. They approve or deny based on medical necessity. 

What to do if your appeal is denied

If your appeal for prior authorization is denied even after your appeals, you can still take Ozempic, but you’ll have to pay for it yourself. According to drugs.com, a 1-month supply of Ozempic retails for about $1,029 with their discount card. Your actual cost depends on the pharmacy you use and other discounts you have. 

You may be eligible to get Ozempic for $25 with Novo Nordisk’s Ozempic Savings Card. The manufacturer, Novo Nordisk, also sponsors a Patient Assistance Program. Patients who qualify can get free Novo Nordisk medications. To find out if you qualify, visit the Novo Nordisk Patient Assistance Program website.

Coupons from prescription discount sites, like GoodRx, SingleCareRx, Optum Perks, and drugs.com, also let you save on Ozempic. You can save anywhere from 3% to 80% on your Ozempic prescription by presenting a coupon to your pharmacy or asking if your pharmacy already has one. 

Real Ozempic user experiences with prior authorization denials

Real Ozempic users share their experiences with prior authorization denials in online forums like Reddit and Ozempic reviews. Some highlights from the Ozempic Reddit thread include:

OpheliaHybrid was denied because they don’t meet the FDA-approved criteria for Ozempic, even though it works for them. They said, “I was given a sample at the doc’s office and I was able to fill one [prescription]. My Dr provided a prior authorization, at my request. I was trying to be proactive. I was denied.”

User Over-Definition-2621 was denied prior authorization after Ozempic helped them lower their A1C below the range approved by their insurance company. They said, “I’ve been on Ozempic for my [blood sugar] & my A1C went down, so did my weight. Now my A1C has gone up and my Ozempic has been denied because my A1C isn’t high enough. So now I have to try other medications [before] I can get Ozempic approved again.”

Happy_55 suggests trying weight loss injection Wegovy (semaglutide). They said, “Some medications require a PA, period, mostly secondary to cost. The requirements for Ozempic and Wegovy were established before the doctor prescribed the medication, so if you’re not a type 2 diabetic, you won’t qualify for Ozempic, period. Many insurances block it outright, others allow 3 months and then the clinician has to demonstrate certain parameters. Check if Wegovy is covered. The criteria for Wegovy are BMI over 30 or BMI over 27 PLUS “weight-related comorbidities”, such as elevated cholesterol and/or triglycerides, high blood pressure, sleep apnea, etc. Good luck!”

To get around prior authorization denials and avoid trouble finding Ozempic in stock, moi2033 suggests “While you sort out your insurance, you may want to consider compounded semaglutide. There’s not a shortage, and it’s much cheaper than Novo Nordisk’s branded Ozempic/Wegovy. It requires a prescription. Some PCPs (primary care providers) will write it. Many people find it’s easier to use a specialty telehealth clinic that provides both the prescription and arranges for an FDA-licensed compounding pharmacy to mail you your medications.”

Ozempic user experiences don’t replace advice from a medical professional. If you’ve repeatedly been denied prior authorization for Ozempic, talk to your healthcare provider about your options. They can help determine whether an alternative medication or treatment is appropriate.

Key takeaway

Ozempic (semaglutide) is an injectable medication proven to lower A1C and approved to lower blood sugar in adults with type 2 diabetes. It also reduces the risk of a major cardiovascular event, such as heart attack or stroke. It can be used off-label for weight loss as well. 

If you’re prescribed Ozempic, you likely need to request prior authorization from your insurance company to get it covered. Prior authorization is a process health insurers use to make sure a medication is medically necessary and prescribed as intended. While there aren’t Ozempic prior authorization criteria for weight loss, you can get approval for Ozempic if you meet the FDA-approved criteria — a diagnosis of type 2 diabetes — and your insurer’s criteria.

To get prior authorization for Ozempic, have your provider evaluate your needs and submit a request. Follow up with your insurance company. If your PA is approved, you can fill Ozempic at your pharmacy of choice and have it covered by insurance. If you’re denied prior authorization for Ozempic, you or your healthcare provider can appeal. Your provider’s office likely has a process in place for this. 

If your appeal is denied, you might still save on Ozempic with savings cards, patient assistance programs, and coupons. Real Ozempic users also suggest trying alternatives like Wegovy or compounded semaglutide. Talk to your healthcare provider if you’re considering alternatives to Ozempic.

Navigate prior authorization for Ozempic with a provider on Klarity

If you’re considering Ozempic, or a similar weight loss medication, don’t wait to consult a healthcare provider. A weight loss specialist on Klarity can evaluate your weight loss needs, give you a prescription for medication, and help you navigate prior authorization. Find a provider on Klarity today and have an appointment in as little as 24 hours.

Sources

Academy of Managed Care Pharmacy, Prior Authorization, Jul. 2019, https://www.amcp.org/about/managed-care-pharmacy-101/concepts-managed-care-pharmacy/prior-authorization

Accreditation Council for Medical Affairs, What is Prior Authorization?, Amanda DeMarco, Dec. 2020, https://www.priorauthtraining.org/prior-authorization/

American Academy of Family Physicians, Precertification, Denials, and Appeals: Reducing the Hassles, Anthony N. Akosa, MD, MBA, Jun. 2006, https://www.aafp.org/pubs/fpm/issues/2006/0600/p45.html 

CoverMyMeds, 7 Common Prior Authorization Hurdles and How to Overcome Them, Miranda Delatore, MSN, RN, NEA-BC, Mar. 2022, https://insights.covermymeds.com/healthcare-technology/prior-authorization/common-prior-authorization-hurdles-and-how-to-overcome-them

DailyMed, Label: Ozempic- semaglutide injection solution, https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=adec4fd2-6858-4c99-91d4-531f5f2a2d79

DailyMed, Label: Wegovy- semaglutide injection solution, https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ee06186f-2aa3-4990-a760-757579d8f77b

Drugs.com, Ozempic Prices, Coupons and Patient Assistance Programs, https://www.drugs.com/price-guide/ozempic

NovoCare, Start A PA, https://www.novocare.com/hcp/diabetes/start-a-pa.html

Novo Nordisk, Ozempic Savings Card, https://www.ozempic.com/savings-and-resources/save-on-ozempic.html

Reddit, Ozempic, https://www.reddit.com/r/Ozempic/comments/

The information provided in this article is for educational purposes only and should not be construed as medical advice. Always seek the guidance of a qualified healthcare professional with any questions or concerns you have regarding your health.

How we reviewed this article: This article goes through rigorous fact-checking by a team of medical reviewers. Reviewers are trained medical professionals who ensure each article contains the most up-to-date information, and that medical details have been correctly interpreted by the author.

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