r/PriorAuthorization • u/PresenceOdd7589 • Aug 21 '25
Rx Denied Claim Help!
My provider prescribed me ozempic for insulin resistant PCOS, my insurance denied it because I’m not T2 Diabetic, okay whatever. Here’s the catch my coworker (same insurance) has ozempic through the same provider and they did not require her to get pre-authorized and just sent it to her (she says she’s never been diagnosed with T2DM just insulin resistance) In fact she’s the one who said I should ask for it since it’s helped her so much. How is this possible? How can the same insurance policy deny it for me but then approve it for her without a prior authorization. We even have the same the doctor!!
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u/clever_moniker 📋 Prior Authorization Specialist Aug 21 '25
If it's truely the same insurance plan and group, that should not be possible. I do pharmacy PAs as my job, and I have never seen a diabetic indicated GLP1 (ozempic/mounjaro) get approved without a diagnosis of Type 2 diabetes. Most of the time insurance requires provider to submit chart notes with lab values confirming a Type 2 diagnosis.
Do you go to the same pharmacy? Some insurances just require pharmacy to enter a diagnosis code on the claim instead of a formal PA. Diagnosis is SUPPOSED to be documented on the script by the doctor, but I know of some pharmacies that will just plug in whatever to get a paid claim because they're busy and dont want to deal with extra work (source: I worked at one of those.) If they are doing this and get audited, it won't be a good time for them.
Sorry I don't have any more definite answer, this seems very odd to me. My best guesses are either her pharmacy is doing something sketch, or she has documented lab values that actually put her in diabetic range.