Does insurance cover Ozempic?

Ozempic is also known by its generic name, semaglutide. It is a once-per-week injection that can help lower blood sugar. Healthcare professionals primarily prescribe it as a treatment option for type 2 diabetes, but it may also help with weight management.

Your health insurance company might cover all or part of the cost of Ozempic. This depends on whether you have been prescribed the drug for type 2 diabetes, which is the use approved by the Food and Drug Administration (FDA). Your coverage might also depend on the details of your plan. Even if coverage is available, you might still have out-of-pocket costs like copays. 

If your insurance company doesn’t cover Ozempic, you can consider requesting that the company make an exception. 

If you need help covering the cost of medications, the free Optum Perks Discount Card could help you save up to 80% on prescription drugs. Follow the links on drug names for savings on that medication, or search for a specific drug here.

When will insurance cover Ozempic? 

Your insurance might cover the cost of Ozempic if a doctor has prescribed it to treat type 2 diabetes. This is the FDA-approved use for the drug. Using Ozempic for another reason, such as weight loss, is considered an off-label use, even if you have a doctor’s prescription. Many health insurance plans will not cover the cost of off-label use of Ozempic.

Even if a doctor has prescribed Ozempic to treat type 2 diabetes, your insurance plan might still not cover the drug. Some insurance plans require you to try other treatments first. Alternatively, the company might ask you to check with them before you purchase the drug to confirm they can cover the cost.

Some Medicare Part D plans cover medications for diabetes, which can include Ozempic. Though Medicare Part D plans do sometimes cover off-label use of medications, there’s no guarantee your plan will cover Ozempic if your prescription is not for type 2 diabetes.

Even if your plan does cover Ozempic, your out-of-pocket costs can depend on how the insurance company classifies the drug. Most insurance plans divide covered drugs into tiers, each with a different cost-sharing formula. In a plan where Ozempic is a tier 2 drug, for example, you might have to pay more out of pocket than you would for tier 1 drugs.

If your insurance company doesn’t cover Ozempic, you can use their appeals process to request that they pay for the cost of the medication. If you’d like to get approval for this kind of exception, a doctor typically has to show that the medication covered by your insurance plan won’t work as well as Ozempic or will cause undesirable side effects. 

What factors can affect insurance coverage?

Many factors can affect whether an insurance company will cover the cost of Ozempic and how much it will cover, including:

• A low cost or generic version of the drug exists: Some insurers won’t cover branded medications if an equivalent generic version is available. But no generic version of Ozempic exists currently.
• You have tried different, lower cost treatments: Some insurers want evidence that a person has tried cheaper therapies before paying for a more expensive medication. This is referred to as step therapy under many plans. 
• You are prescribed Ozempic for off-label use: Your insurer might only cover the FDA-approved use for Ozempic, which is to treat type 2 diabetes.
• You have prior authorization: This process involves a healthcare professional getting preapproval for the drug from the insurance company before they prescribe it. This ensures that you have coverage under your plan.
• Your insurer has decided to stop covering the drug: Sometimes, an insurance plan will cover a drug like Ozempic but then stop paying for the medication. If this happens, you can sometimes get a one-time refill. You can also ask the insurer to keep covering the drug by filing an appeal. 

Even if Ozempic appears in your drug plan’s formulary or list of covered medications, you might still have to pay some money out of pocket. Your costs might include your plan’s deductible, as well as a copay or coinsurance.

How to check your insurance plan’s coverage for Ozempic

You have a few ways to find out whether your current insurance plan covers Ozempic and whether you need prior authorization. This includes:

• Visiting your insurance company’s website: This can help you locate the formulary of your specific plan.
• Reviewing the summary of benefits and coverage of your plan: You can request this information from your insurer or view a copy online via your healthcare marketplace account.
• Reviewing the paper materials your insurer sent you when you signed on to your plan: These documents should also include a list of covered medications.
• Calling your insurance company: You can use the general number for plan members. You can ask the agent whether your plan covers a certain medication.

Sometimes, an insurance company’s drug formulary can be long and hard to read. The important details, such as whether the drug is approved for off-label use, might not be obvious. Your insurance company should be able to help you interpret the plan.  

How can Optum Perks help?

A prescription discount card offers a great way to help you save money on your medication. While you cannot use it in combination with your health insurance, you can compare both to see which option will give you the biggest savings.

Optum Perks offers a free Discount Card that could help you save up to 80% on FDA-approved prescription drugs, such as Ozempic. You can search for a specific drug here to see how much you could save on your medication.

Summary

Your insurance company might cover the cost of Ozempic, especially if it’s prescribed to treat type 2 diabetes. Even still, you might need to pay a copay for the medication out of pocket. 

Some insurers may require you to get prior authorization for coverage of Ozempic. This involves a doctor filling out additional paperwork that shows you need the medication. 

An insurer might cover Ozempic and then remove it from its list of covered medications. If this happens to you, it is possible to request an exception, so the plan will continue to cover the drug. 

If your plan has never covered Ozempic, it is also possible to request that it does so in your case. You need to show that other medications won’t work as well or will cause negative side effects. 

Download the free Optum Perks Discount Card to save up to 80% on some prescription medications.