Will my insurance cover Ozempic?
Key highlights
- Ozempic is a GLP-1 agonist approved by the FDA for type 2 diabetes. However, it is also used off-label for weight loss, PCOS, cholesterol, prediabetes, and fatty liver.
- The list price for a month’s supply of Ozempic is $968.52 without insurance. However, the retail price may range from $1,000 to $1,200.
- Most health insurance plans cover Ozempic for FDA-approved use (type 2 diabetes) but do not offer coverage when used as a weight loss medication.
- If your insurance plan does not Ozempic weight loss, you can check the formulary to find alternative weight management drugs covered by your plan.
Table of contents
According to a 2021 CDC report, 38.4 million people in the U.S. have diabetes, and around 90-95% of them have type 2 diabetes. Doctors often prescribe medication to manage the condition, in addition to lifestyle modifications. Glucagon-like peptide-1 (GLP-1) drugs like Ozempic are widely used for diabetes management. Some people also use GLP-1 receptor agonists as weight loss medications.
In a recent KFF Health Tracking Poll, 62% of the adults taking GLP-1 drugs (Ozempic/Wegovy/Mounjaro) mentioned taking them to treat chronic health conditions, including type 2 diabetes and heart diseases. Ozempic and Wegovy are popular once-weekly injectable drugs of the GLP-1 class. Wegovy is FDA-approved for weight loss in obesity or overweight, whereas Ozempic is usually prescribed for managing blood sugar levels in type 2 diabetes.
Most health insurance plans cover the cost of Ozempic for its FDA-approved use in type 2 diabetes mellitus. However, insurance companies typically do not offer coverage for Ozempic when used off-label for weight loss or managing another medical condition.
Your final out-of-pocket costs depend on the insurance plan’s benefits, deductibles, copays, and coinsurance.
What is Ozempic?
Ozempic is a glucagon-like peptide-1 (GLP-1) agonist that is manufactured by Novo Nordisk. It works by imitating the actions of a gut hormone known as GLP-1 and reducing blood glucose levels after eating, reducing glucose production in the liver, and slowing the movement of food out of the stomach. It is currently FDA-approved to treat people with type 2 diabetes. While Ozempic will also affect appetite and increase the feeling of fullness, it is known to cause weight loss as a side effect, however it is not currently approved for chronic weight loss management.
Does my health insurance cover Ozempic?
Your health insurance may or may not cover Ozempic, depending on your medical diagnosis and drug coverage offered in your health insurance plan. Most insurance providers cover Ozempic for type 2 diabetes but may not cover it for off-label uses such as pre-diabetes PCOS or weight loss. If you are commercially insured and your insurance company covers Ozempic, you can pay as little as $25 per month.
On a case-by-case basis, a healthcare provider can appeal an insurance company’s decision and specify that Ozempic is medically necessary for your medical condition and should be covered.
Some insurance companies might offer Ozempic coverage for weight management if you meet certain criteria, such as previously using another medication that did not work for you. In case you do not qualify for Ozempic coverage for weight loss, you might be able to get insurance coverage for Wegovy or another FDA-approved weight loss medication.
Does Medicare cover Ozempic?
Medicare provides healthcare coverage for people 65 or over, people with end-stage kidney disease, and young people with disabilities. Most Medicare prescription drug plans, including Medicare Part D and Medicare Advantage Prescription Drug Plans (MD-PD), cover diabetes medications, including Ozempic. The price you pay for Ozempic will depend on your copay and whether you have met your required deductible.
However, since the implementation of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA), it does not cover Ozempic as a weight loss medication. Drug coverage may change over time. Thus, it is best to check the prescription medication coverage for your plan.
To check if your Medicare prescription drug plan covers Ozempic, you can review your plan’s formulary which is a list of all of the drugs that are covered by your insurance plan and the respective tier for each drug. Medications that are listed at higher tiers will be more expensive.
In case your plan covers Ozempic but there are other GLP-1 drugs that are listed at a lower tier, and subsequently at a lower cost to you, your healthcare provider may be able to request an exception from your insurance company for you to receive authorization to pay a lower copay for Ozempic. If not, your doctor may be able to prescribe an alternative GLP-1 medication that is at a lower tier in your insurance plan.
RELATED: Does Medicare cover Ozempic?
Does Medicaid cover Ozempic?
Medicaid offers health insurance to low-income families, children, pregnant women, and people with specific disabilities. The insurance plan covers most GLP-1 receptor agonists for type 2 diabetes management, including semaglutide drugs like Ozempic.
Medicaid’s prescription coverage may vary by state, as every state has its requirements for prior authorization, step therapy, quantity limits and other plan coverage details. Medicaid-insured individuals do not receive Ozempic coverage for weight management in most states, with a few exceptions. To find out if your Medicaid plan covers Ozempic, contact your state’s Medicaid agency for plan and coverage details.
RELATED: Does Medicaid cover Ozempic?
Does commercial (private) insurance cover Ozempic?
Most commercial (private) insurance providers offer Ozempic coverage for type 2 diabetes to control blood sugar levels. However, weight-loss medications are generally not covered by employer-sponsored plans in the United States. Under the Affordable Care Act’s (ACA, also known as Obamacare) essential health benefits, private insurance plans are only required to provide coverage for obesity screening and counseling.
Even if your insurance company covers Ozempic for weight loss, there may be certain conditions for the medication to be considered medically necessary, such as making behavioral modifications and/or having a minimum body mass index (BMI).
The manufacturer of Ozempic, Novo Nordisk, provides an online tool to help estimate the cost of Ozempic with your individual insurance plan.
If you have commercial or private insurance (e.g. employer-sponsored insurance), you may be eligible to pay as little as $25 for a 1-month, 2-month, or 3-month supply of Ozempic with Ozempic Savings Card which is valid for up to 24 months with a maximum savings of $150 for a 1-month prescription, $300 for a 2-month prescription, and $450 for a 3-month prescription.
Will insurance cover Ozempic for weight loss?
Ozempic is not approved for weight loss by the U.S. Food and Drug Administration. However, clinical trials have shown almost 15% average weight loss (12.4% more than placebo). Ozempic is commonly prescribed off-label for weight loss.
Most insurance companies do not provide coverage for weight management as the medication is not approved for weight loss. Some health insurance plans might cover it for weight loss, but many do not. Instead, they may offer coverage for an alternative GLP-1 medication like Wegovy or Saxenda. If your plan does not cover Ozempic for weight loss, you can ask your healthcare provider for an alternative or discuss the possibilities with the insurance company.
Will insurance cover Ozempic for prediabetes?
Insurance companies usually offer drug coverage for FDA-approved uses, and Ozempic is only approved for type 2 diabetes. As such, most insurance companies do not provide coverage for prediabetes. However, some insurance plans might cover prediabetes management medication if it meets their specific criteria.
Will insurance cover Ozempic for PCOS?
Polycystic ovarian syndrome (PCOS) affects 10% of women of reproductive age. 40% of women with PCOS are obese and have a high BMI. Doctors often prescribe diabetes medications along with lifestyle changes to manage the condition. While Ozempic is approved for type 2 diabetes, it is showing promising results in PCOS management in females with obesity. Your insurance might cover Ozempic when prescribed for type 2 diabetes but not PCOS. You can ask your insurance company if there’s a possibility you can get Ozempic coverage for the condition.
Will insurance cover Ozempic for high cholesterol?
Ozempic does not have any ingredient that directly manages blood cholesterol. However, studies have shown that obese adults who reduced weight also showed lowered levels of LDL cholesterol. Thus, many people use it for managing high cholesterol to avoid cardiovascular diseases.
Most insurance plans cover Ozempic only for its approved uses, and you might not get coverage for off-label uses like cholesterol management.
How do I get my insurance to cover Ozempic?
Most insurance plans cover Ozempic for blood glucose management for people with type 2 diabetes, but some might ask you to try an affordable alternative like metformin. To obtain insurance coverage for Ozempic, you can increase the chances of your insurance provider covering this weight loss drug by following these steps:
- Review your insurance plan to see if your health insurance plan covers the drug for one or more uses. Visiting their website can help you better understand if Ozempic is a covered medication.
- Get a prescription from your healthcare provider for Ozempic.
- If required by your insurance company, obtain a prior authorization for Ozempic. Your healthcare provider may need to provide confirmation that you have type 2 diabetes and state that Ozempic is medically necessary for your condition.
- If your insurance company denies coverage, you can appeal the decision by writing an appeal letter in attempt to reverse the decision.
Why is Ozempic denied by insurance?
Many insurance plans do not cover Ozempic for prescriptions other than type 2 diabetes due to multiple reasons:
Off-label use
Insurance providers generally cover Ozempic based on its FDA-approved uses so your insurance may have Ozempic coverage for type 2 diabetes but not off-label uses like weight loss, PCOS, and cholesterol management.
Cosmetic issue
Some insurance providers consider obesity a cosmetic issue instead of a chronic disease.
Cost
Typically, insurance plans do not cover costly drugs unless necessary. Thus, your insurance provider might not offer Ozempic coverage for weight loss and other off-label uses. Sometimes, your insurance company might consider your request with a doctor’s prescription and prior authorization. If Ozempic is on a high tier in the insurance company’s formulary, you may have to pay significant out-of-pocket costs.
MMA
Since the implementation of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA), insurance does not cover Ozempic for off-label weight loss and is not mandated to cover weight loss medications.
How much does Ozempic cost with and without insurance?
The list price for Ozempic is $968.52 per month’s supply without insurance, according to Novo Nordisk. However, the retail price may range from $1,000 to $1,200. As there is currently no generic available for Ozempic, the cost remains high.
The cost of Ozempic may depend on the pharmacy you visit, your location, your insurance coverage, your prescribed dosage, and eligibility for the Ozempic savings card or NovoCare patient assistance program. Ozempic Savings Card may also help you people with commercial or private insurance reduce their out-of-pocket costs to as low as $25 per month.
Are there cheaper alternatives to Ozempic for weight loss?
Ozempic is one of the more affordable GLP-1 medications. It is cheaper than Wegovy, Mounjaro, Zepbound, Saxenda, Trulicity, and Rybelsus.
However, if you have commercial or private insurance such as an employer-sponsored plan, and do not have any government insurance such as Medicare, Medicaid, or Tricare for example, you may qualify for the Zepbound savings card, which lowers cost of a one-month prescription of Zepbound to $25 (with insurance coverage) or $550 (without insurance coverage). Zepbound is an FDA-approved drug for chronic weight loss management.
You can also consider obtaining a prescription for compounded semaglutide which is less expensive and has the same active ingredient as Ozempic and Wegovy.
How to get Ozempic for free
You can get Ozempic for free through the Novo Nordisk Patient Assistance Program. The program offers over a dozen medications for free to eligible individuals. To qualify for patient assistance, you must:
- Be a U.S. citizen or legal resident
- Be a low-income household (total household income at or below 400% of the federal poverty line)
- Have a medical diagnosis of type 2 diabetes (weight loss is not eligible)
- Have no insurance
How to save on Ozempic
If you do not qualify for the patient assistance program for Ozempic, there are other options to consider. People with commercial insurance can also get copay assistance with the Ozempic Savings card.
The Savings Card offers:
- $150 off 1-month supply
- $300 off 2-month supply
- $450 off 3-month supply
You may have to pay as little as $25 for a one-month, two-month, or three-month Ozempic supply for type 2 diabetes management. This offer is valid for up to 24 months. However, it is not for individuals enrolled in government-assisted insurance like Medicaid, Medicare, Tricare, and other government insurance plans.
You can also save money by purchasing compounded semaglutide (the same active ingredient as Ozempic and Wegovy) at a lower price through the NiceRx Weight Loss Program.
Bottom line
Ozempic is an FDA-approved drug for type 2 diabetes, but people also commonly use it off-label for weight loss. Health insurance plans usually cover medications for their FDA-approved uses and therefore, most insurance companies will only cover Ozempic for people with type 2 diabetes and may not cover weight loss drugs.
If your insurance company does not cover Ozempic, you can consider other options such as the NovoCare patient assistance program, Ozempic Savings Card, compounded semaglutide, or discuss alternative medications with your healthcare provider.
