How to get semaglutide covered by insurance

Semaglutide, a GLP-1 receptor agonist, is the active ingredient in popular medications like Ozempic, Wegovy, and Rybelsus. While highly effective for managing type 2 diabetes and aiding in weight loss, the out-of-pocket costs for these medications can be steep.

Understanding how to get semaglutide covered by insurance can help make this weight loss treatment more affordable and accessible.

Why do you need insurance for semaglutide for weight loss?

These medications can be quite costly. Without insurance, the out-of-pocket costs can reach over a thousand dollars per month, making it a financial burden for many. Having insurance coverage can help to offset these costs and make them more accessible.

Semaglutide cost with insurance (and without)

Semaglutide is the active ingredient in multiple brand name medications as well as compounded semaglutide. Pricing will vary by medication:

Ozempic. The current list price for Ozemic is $968 for a 30-day supply.
Wegovy. The current list price for Wegovy is $1349 for a 30-day supply.
Rybelsus. The current list price for Rybelsus is $968 for a 30-day supply.
Compounded Semaglutide*. The list price for compounded semaglutide will vary by pharmacy. You can get compounded semaglutide on Heally for $299 per month.

* It should be noted that compounded semaglutide will not be covered by insurance. Many choose to use compounded semaglutide to offset the cost of the brand name medications when insurance won’t cover costs.

The out of pocket costs can be offset by location, pharmacy, and eligibility for savings and assistance programs.

With insurance, the cost of these medications will vary. Novo Nordisk, the manufacturer for all FDA-approved semaglutide medications, provides an online tool to estimate the cost with your insurance plan:

Is semaglutide covered by insurance?

There is no simple cookie cutter answer to this question. Coverage will depend on the insurance company’s policies, individual plan, diagnosis, and medical history.

Currently, Wegovy is the only semaglutide medication that is FDA-approved for weight loss. While Ozempic and Rybelsus are prescribed off-label for weight loss, this can impact their coverage eligibility.

Ozempic insurance coverage

Ozempic is FDA_approved for the treatment of type 2 diabetes, but it is very commonly prescribed off-label for weight loss. Unfortunately, many insurance companies have very strict policies about covering medications prescribed for non-approved uses.

Your insurance company will not automatically cover Ozempic for weight loss. You will need to speak with them to determine if there may be exceptions.

Wegovy insurance coverage

While Wegovy is FDA-approved for weight loss, your insurance plan may still not cover the treatment. Unfortunately, insurance companies are not required to cover weight loss treatment options—they are, however, required to provide obesity screening and counseling under the Affordable Care Act.

You will need to review your current plan to determine if weight loss treatments are covered.

Rybelsus insurance coverage

Like Ozempic, Rybelsus is only FDA-approved for type 2 diabetes treatment and is considered off-label for weight loss. This medication is not as commonly prescribed off-label for weight loss, so negotiating coverage may be more difficult.

What insurance covers semaglutide?

There is currently no curated list of insurance companies that cover weight loss treatment. This is also very plan dependent. Even if your insurance company offers weight loss coverage, your individual plan may not.

You can review your current plan and your company’s prescription “formulary,” which lists covered medications and whether or not they have specific eligibility requirements.

How to get semaglutide covered by insurance: step-by step guide

If they don’t cover weight loss treatments or have strict policies on off-label use…

1. What insurance covers semaglutide

If you’re considering switching insurance providers to one who provides semaglutide insurance coverage, follow these steps to ensure you find the right coverage:

Research Insurance Providers: Look for insurance companies that offer plans specifically covering weight loss medications. You can also check specifically for semaglutide medication coverage, including Ozempic, Wegovy, and Rybelsus.
Review Plan Details: Examine the coverage specifics of each plan, focusing on policies that include weight loss medications or off-label use of semaglutide. Ensure that the plan you choose aligns with your treatment goals and your other medical needs.
Confirm Coverage with Insurer: You’ll want to be sure before you make the switch. Reach out to the insurance provider to verify whether they offer semaglutide insurance coverage for weight loss. Make sure to ask about any additional eligibility requirements that may be required, like prior authorization or documentation.
Switch Plans: After identifying a plan that meets your needs, complete the enrollment process and confirm your coverage before starting semaglutide to ensure you have the coverage you need for your treatment.

2. How to get insurance to cover semaglutide

If changing your insurance plan isn’t an option, you may still be able to negotiate for coverage of semaglutide with your current insurance provider. Try the following:

Review Your Current Plan: Begin by examining your insurance policy to see if it offers any coverage for weight loss medications or off-label uses of semaglutide. Take note of any exclusions, requirements, or stipulations, such as prior authorization.
Request Prior Authorization: Ask your doctor to help you submit a prior authorization request to your insurance company. You will need to prove the medical necessity, so make sure you have the proper diagnoses and documentation.
Appeal a Denial: If your initial request is denied, don’t lose hope. File an appeal with your insurance company, supplying additional documentation that reinforces the necessity of semaglutide as part of your treatment plan.

Unfortunately, there is no guarantee that this process will work. You may still not be able to procure semaglutide insurance coverage to offset the costs. Thankfully, there are additional options.

What to do if I have a semaglutide prescription, but insurance refuses to pay?

If you cannot negotiate for semaglutide insurance coverage with your insurance company, you do still have options to offset the out of pocket costs for your medication.

Eligible individuals can apply for Novo Nordisk’s Patient Assistance Program, but the criteria is strict.

Novo Nordisk also offers savings cards for some of their medications. If you’re enrolled in a commercial (or private) insurance plan and are not enrolled in any government, state, or federally funded medical or prescription benefit programs, you may be eligible. They offer:

An Ozempic Savings Card, where you could pay as little as $25 for a 1-, 2-, or 3-month supply for up to 24 months.
A Wegovy Copay Card, which can lower costs from $1349 to as little as $650.
A Rybelsus Savings Card, where eligible patients can pay as little as $10 for a 1-, 2-, or 3-month supply.

Discuss your options with your healthcare provider

If you’re ready to discuss your options with a healthcare provider, Heally can connect you to a weight loss doctor to help you make the right choice for you.

Schedule your consultation today and explore your options.