How to appeal an Ozempic denial

What Ozempic is approved for

If you have type 2 diabetes and were denied

If Ozempic was prescribed for weight loss

Reading the denial letter

Formulary exceptions

What to send with the appeal

Medicare and Medicaid

Questions people ask

Sources

1. U.S. Food and Drug Administration: Drugs@FDA: FDA-Approved Drugs (Ozempic, NDA 209637)12/05/2017 ORIG-1 Approval Type 1 - New Molecular Entity
2. U.S. Food and Drug Administration: OZEMPIC (semaglutide) injection prescribing information, January 2025 (Drugs@FDA)to reduce the risk of sustained eGFR decline, end-stage kidney disease and cardiovascular death in adults with type 2 diabetes mellitus and chronic kidney disease
3. U.S. Food and Drug Administration: NDA 209637/S-003 Supplement Approval letter for Ozempic (January 16, 2020)provides for the addition of an indication to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction or non-fatal stroke) in adults with type 2 diabetes mellitus and established cardiovascular disease
4. U.S. Food and Drug Administration: NDA 209637/S-025 Supplement Approval letter for Ozempic (January 28, 2025)provides for a new indication to reduce the risk of sustained estimated glomerular filtration rate (eGFR) decline
5. Cigna Healthcare: Drug Coverage Policy IP0701: Diabetes – Glucagon-Like Peptide-1 Agonists for Employer Plans (effective 06/15/2026)Wegovy (semaglutide tablets and subcutaneous injection) contains the same chemical entity as Ozempic and is indicated at a higher dose for chronic weight management.
6. KFF: 2026 Employer Health Benefits SurveyHealth plans generally have covered these medications when prescribed for people with diabetes
7. Peterson-KFF Health System Tracker: Insurer strategies to control costs associated with weight loss drugsstep therapy is much less commonly used as a utilization management tool, with fewer than 1 in 4 Marketplace plans requiring step therapy for each of the drugs included in this analysis
8. HealthCare.gov: Internal appealsYou must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied.
9. Cigna Healthcare: Diabetes – Glucagon-Like Peptide-1 Agonists Prior Authorization Policy (Cigna National Formulary, review date 06/03/2026)Weight Loss Treatment. The products in this policy are not FDA-approved for weight loss.
10. Legal Information Institute, Cornell Law School: 42 U.S. Code § 1395w-102 - Prescription drug benefitswhich may be excluded from coverage or otherwise restricted under section 1396r–8(d)(2) of this title
11. Legal Information Institute, Cornell Law School: 42 U.S. Code § 1396r-8 - Payment for covered outpatient drugs(A) Agents when used for anorexia, weight loss, or weight gain.
12. Centers for Medicare & Medicaid Services: Medicare GLP-1 BridgeThe Medicare GLP-1 Bridge is a short-term demonstration run by CMS that will provide eligible Medicare Part D beneficiaries with access to certain GLP-1 drugs between July 1, 2026, and December 31, 2027.
13. Medicare.gov: Weight loss drugsZepbound® (KwikPen® only. The program doesn’t cover single-dose Zepbound® vials or pens)
14. eCFR (Office of the Federal Register): 29 CFR 2560.503-1 -- Claims procedureReference to the specific plan provisions on which the determination is based
15. HealthCare.gov: Getting prescription medicationsVisit your insurer’s website to review a list of prescriptions your plan covers
16. Centers for Medicare & Medicaid Services: Summary of Benefits and Coverage template (accessible format)Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
17. eCFR (Office of the Federal Register): 45 CFR 156.122 -- Prescription drug benefitsA health plan must make its determination on a standard exception and notify the enrollee or the enrollee's designee and the prescribing physician (or other prescriber, as appropriate) of its coverage determination no later than 72 hours following receipt of the request.
18. Novo Nordisk: Support Starts Here for Patients Taking Novo Medicines | Novocare®offers the guidance, savings, and support you need to keep moving forward
19. HealthCare.gov: External ReviewAny denial that involves medical judgment where you or your provider may disagree with the health insurance plan
20. eCFR (Office of the Federal Register): 42 CFR 423.578 -- Exceptions processThe Part D plan sponsor must grant an exception whenever it determines that the drug is medically necessary, consistent with the physician's or other prescriber's statement under paragraph (b)(5) of this section, and that the drug would be covered but for the fact that it is an off-formulary drug.
21. Medicare.gov: Appeals in a Medicare drug planIf you're asking for an exception, your prescriber must provide a statement explaining the medical reason why the exception should be approved.
22. eCFR (Office of the Federal Register): 42 CFR 423.568 -- Standard timeframe and notice requirements for coverage determinationsbut no later than 72 hours after receipt of the physician's or other prescriber's supporting statement
23. eCFR (Office of the Federal Register): 42 CFR 423.572 -- Timeframes and notice requirements for expedited coverage determinationsbut no later than 24 hours after receipt of the physician's or other prescriber's supporting statement
24. KFF: Medicaid Coverage of and Spending on GLP-1sMedicaid coverage of GLP-1 drugs for obesity treatment is optional for states, while coverage for other indications (diabetes, cardiovascular disease, and sleep apnea) is required.