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Reviewed by Evidence reports that people using semaglutide (Ozempicยฎ, Wegovyยฎ) may lose 14.9% of their baseline weight after 15 months of treatment. Consequently, Ozempicยฎ has earned its reputation as a weight loss aid.
Since the FDA exclusively approves Ozempic to help control blood sugar levels in the 38 million Americans living with diabetes, particularly those with type 2 diabetes, most health insurance companies will cover Ozempic for diabetes treatment but not for weight management.
While doctors might prescribe Ozempic off-label for obesity, you will likely have to cover the cost yourself. Given that Ozempic can be expensive, you might wonder: How to get your insurance to cover Ozempic? Can you get free Ozempic? Keep reading to find out more about Ozempic costs and insurance coverage.
Table Of Contents:
Ozempic Overview
Ozempicยฎ (semaglutide) is an injection-type medication belonging to a class of drugs known as GLP-1 receptor agonists. It helps control blood sugar levels in adults with type 2 diabetes. Ozempic mimics the action of a gut hormone called GLP-1 (glucagon-like peptide-1), targeting areas of the brain involved in appetite and food intake.
By stimulating insulin release, reducing the amount of glucose produced by the liver, and slowing down food digestion, Ozempic suppresses appetite and induces a sensation of fullness. As a result, people eat less, donโt crave high-fat foods, and ultimately lose weight.
Ozempicยฎ is administered once a week via pre-filled pens containing multiple doses of the drug, either on the upper arm, thigh, or stomach. Patients typically start with a lower dose to minimize Ozempic side effects, gradually increasing to a therapeutic dose (2 mg max dose/week) as directed by the healthcare provider.
How Much Does Ozempic Cost without Insurance?
The cost of Ozempic per month can change depending on your insurance coverage, the pharmacy you choose, and your prescribed dosage.
Today, the list price for Ozempicยฎ is $935.77 per pen for all strengths or $11,229 per year if you pay the full price. However, the retail price can differ and might be higher, up to $1,200. Since no generic versions of this medication exist, the only way to reduce the Ozempic price is through health insurance or savings programs.
Will My Insurance Cover Ozempic?
With the high list price, Ozempic can be quite difficult to afford without insurance. So, will insurance cover Ozempic for prediabetes? Whether your insurance covers Ozempic depends on your specific plan and medical condition. Generally, insurance providers are more likely to cover Ozempic for patients with type 2 diabetes, but coverage for weight loss is less common.
Here is a detailed look at how various insurance providers approach coverage for Ozempic:
Does Medicaid Cover Ozempic for Weight Loss?
The availability of Medicaid coverage for Ozempic differs from state to state. Itโs not typically covered unless prescribed as a treatment for type 2 diabetes. Medicaid insurance won’t cover Ozempic or other GLP-1 agonists prescribed off-label for weight loss.
For Medicaid Ozempic coverage, you will need:
- Medical documentation confirming your type 2 diabetes diagnosis.
- Check if Ozempic is a preferred drug on your state’s Medicaid formulary.
- A recent A1C test result (indicates blood sugar level over the past 2โ3 months)
- Evidence of step therapy with medications like metformin.
- Check if you need prior authorization to ensure Ozempic is medically necessary.
Each state Medicaid program has its formulary and criteria for covering medications. The best action is to contact your Medicaid agency for details about your health plan.
Does Medicare Cover Ozempic for Weight Loss?
By law, the answer is no. Medicare does not cover prescription medications for weight loss. This exclusion means Ozempic can only be covered if prescribed for diabetes treatment, primarily through Medicare Part D, Medicare’s prescription drug plan section.
Many Medicare Advantage plans include Part D coverage, and the guidelines for covering Ozempic are usually the same. However, full coverage may not be available, and copays or coinsurance will vary depending on the placement of the Ozempic tier.
For Medicare Ozempic coverage, you will need:
- Review your Medicare planโs formulary to confirm Ozempic coverage and tier placement.
- Get the necessary documentation to show you need the medication.
- Understand Medicare may require you to try other medications before approving Ozempic.
Does Blue Cross Blue Shield Cover Ozempic for Weight Loss?
Blue Cross Blue Shield (BCBS) may cover Ozempic for treating type 2 diabetes, depending on the specific plan and prior authorization requirements.
However, BCBS typically does not cover Ozempic for weight loss but may cover Wegovy, which has the same active ingredient and is approved for weight management. If a patient has a Body Mass Index (BMI) of 30 or more, BCBS plans sometimes cover weight loss drugs before you meet your deductible since they can be considered preventive medicine.
Check your plan coverage details to know if you are eligible.
Does Aetna Cover Ozempic for Weight Loss?
Like other insurance companies, Aetna prescription coverage for Ozempic includes those with type 2 diabetes, subject to specific criteria and prior authorization requirements. Aetna coverage requires that the patient has type 2 diabetes and either:
- Has been on GLP-1 agonist therapy for at least three months with a reduction in A1C levels.
- Has had an inadequate response, intolerance, or contraindication to metformin.
- Requires combination therapy with an A1C of 7.5% or greater.
Ozempic coverage includes specific limits on dispensing amount, and approval typically lasts 12 months. The policy applies to outpatient settings. For more detailed information, check Aetna’s policy on Ozempic.
Does Kaiser Cover Ozempic?
Kaiser Permanente covers Ozempic as a prescription drug for weight loss only for Northwest members with coverage for weight loss medications.
Ozempic must be paid at the cash price for the rest of the members. Remember that once you reach a healthy body mass index (BMI), Kaiser may cut off Ozempic coverage. To confirm your benefits, contact a Kaiser Permanente pharmacy in your region.
Does United Healthcare Cover Ozempic for Weight Loss?
United Healthcare covers Ozempic as a Tier 3 medication under its Essential Drug Plan for treating type 2 diabetes. This means certain limitations apply, including the requirement for prior authorization, step therapy, and quantity limits.
However, under United Healthcareโs Advantage Drug Plan, Ozempic is covered as a Tier 2 medication, which may result in a lower copayment for members. United Healthcare doesnโt cover it for weight loss since it’s not FDA-approved for that purpose.
To be eligible for Ozempic coverage under United Healthcare, you will need:
- Diagnosis of type 2 diabetes.
- Get documentation and a prescription for Ozempic from your healthcare provider.
- Additional prerequisites, such as prior authorization or step therapy with metformin.
- Compliance with any plan-specific requirements and treatment guidelines.
- Check the specifics of your plan for coverage details and any potential limitations.
Does Cigna Cover Ozempic For Weight Loss?
Cigna generally only covers prescription medication when prescribed for a diagnosis that matches its FDA-approved use. Since Ozempic is considered off-label for weight loss, Cigna wonโt offer coverage under this scenario.
Following other insurance companies’ guidelines, Cigna’s coverage criteria for Ozempic may also include requirements such as having been diagnosed with type 2 diabetes and having tried metformin without success. Prior authorization may also be necessary before you get the coverage.
Does Anthem Cover Ozempic for Weight Loss?
Anthem typically does not cover Ozempic for weight loss purposes.
Their coverage criteria for GLP-1 agents, including Ozempic, respond to treating type 2 diabetes. As a rule of thumb, they require verification of a diagnosis of type 2 diabetes, along with specific laboratory or clinical criteria, such as high hemoglobin A1C levels or fasting plasma glucose levels.
Does Tricare Cover Ozempic?
Tricare may cover Ozempic only if you need it for diabetes treatment, as it is FDA-approved for this purpose. Tricare may not provide coverage for weight loss purposes for Ozempic.
To ensure coverage for Ozempic under Tricare:
- You will need a prescription from your licensed healthcare provider.
- You must meet the criteria outlined in the Tricare Prescription Drug Coverage policy.
- You will need prior authorization and medical forms to show you need Ozempic.
How Much Does Insurance Cover Ozempic?
Your insurance coverage range will change according to your planโs details. You may pay as little as $25 or as much as $700 if you haven’t met your planโs deductible. Some plans may have a copayment (a fixed amount you pay per prescription) or coinsurance (a percentage of the drug’s cost you pay).
Yet, Novo Nordisk, the manufacturer of Ozempic, offers a savings card to help you reduce the Ozempic price. Savings amounts go:
- Up to $150 off for a 1-month supply.
- Up to $300 off for a 2-month supply.
- Up to $450 off for a 3-month supply.
The savings card applies to eligible commercially insured patients with coverage for Ozempic for up to 24 months. You can get the discount by texting BEGIN to 21848 or registering on Ozempic Savings.
How to Get Insurance to Cover Ozempic for Weight Loss?
As you can tell, getting insurance to cover Ozempic for weight loss is not common. To be eligible for Ozempic coverage, you must provide medical documentation for a type 2 diabetes diagnosis and follow company guidelines.
To increase the chances of getting insurance to cover Ozempic, you can follow these steps:
- Contact your insurance provider to know your plan’s coverage for medications.
- Review your list of covered medications to see if Ozempic is included.
- Schedule an appointment with your doctor to monitor your blood sugar levels.
- If blood sugar levels are abnormal, ensure documentation.
- If you need prior authorization, talk to your doctor and submit all required paperwork.
- Provide evidence that you have tried other diabetes treatments without success.
- Draft a detailed appeal letter if your initial request for coverage is denied.
Can You Get Ozempic for Free?
Yes, you may get Ozempic for free through the Novo Nordisk Patient Assistance Program (PAP). To qualify, you must be a U.S. citizen or legal resident, have a household income at or below 400% of the federal poverty level, and either have no insurance or be covered by Medicare.
The program provides free medications for eligible individuals without registration charges or monthly fees. For more details and to apply, visit the Novo Nordisk PAP webpage.
Will Insurance Cover Ozempic? โ Final Considerations
Most insurance plans cover Ozempic for type 2 diabetes but are less likely to cover it for weight loss. To determine your out-of-pocket costs and personalized advice on Ozempic coverage and financial assistance, consult your healthcare provider, verify your insurance company guidelines, and visit local pharmacies.
To reduce the cost of your treatment, you can explore options like the Novo Nordisk Patient Assistance Program and Savings Cards. If you are considering Ozempic for weight loss, you should check for FDA-approved weight loss medications like Wegovy, which are covered under different terms and may be approved for you.
People Also Ask
Is Ozempic covered by insurance?
Yes, most insurance plans cover Ozempic for treating type 2 diabetes. However, prior authorization, lab tests and step therapy with metformin are often required.
Does insurance cover Ozempic for weight loss?
Health insurance companies will mostly cover prescription medications for their FDA-approved uses. Since Ozempic for weight loss is considered off-label, most insurance providers wonโt cover Ozempic for this purpose. Check your health plan details for more information.
Will insurance cover Ozempic for prediabetes?
Insurance typically does not cover Ozempic for prediabetes as its use is considered off-label. However, some plans might cover weight loss drugs as preventive medicine before meeting the deductible. Check your health plan for details on your coverage.
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Page Sources
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