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Your provider must submit: Completed appeal form (available on Ambetter's provider portal) Letter of medical necessity explaining why Ozempic is required Complete medical records including: Diabetes diagnosis with ICD-10 code A1C lab results from past 90 days Documentation of metformin trial (prescription records, pharmacy fill history) Documentation of metformin failure (follow-up A1C showing inadequate response) or intolerance (chart notes describing GI side effects) Current medication list BMI calculation and weight history Any cardiovascular comorbidities The internal review is completed within 30 days for standard appeals, 72 hours for expedited appeals

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Patients with arrhythmias, coronary artery disease, or hypertension need close monitoring

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