Disclaimer: This content about how does Ozempic work is for educational purposes only and does not constitute medical advice. Always consult a qualified healthcare provider before starting, stopping, or changing any weight-management therapy.
Ozempic is a brand-name medication approved by the FDA to treat type 2 diabetes, helping manage blood sugar levels. But, when combined with diet and exercise, it has also shown to be an effective weight loss aid in Clinical Trials.
Unfortunately, despite its benefits, getting Ozempic insurance coverage can be challenging.
Why do you need insurance for Ozempic?
Ozempic can be expensive when paying out of pocket, with the cost often reaching up to a thousand dollars per month. The cost of Ozempic with insurance can be much more affordable, significantly reducing the financial burden.
Ozempic cost with insurance (and without)
The current list price for Ozempic is approximately $968 per injection pen, which contains four doses, or one month’s supply. The actual cost of Ozempic can vary depending on several factors, including:
- Prescription dosage
- Location
- Pharmacy
- Insurance coverage
- Eligibility for savings cards and patient assistance programs
If your insurance plan covers Ozempic, you could pay significantly less. The final cost will depend on your specific plan, copay, and any applicable deductibles. Novo Nordisk, the manufacturer of Ozempic, makes it simple to estimate the cost with your insurance plan thanks to their online tool.
Is Ozempic covered by insurance?
Yes and no. While Ozempic is often covered for the treatment of type 2 diabetes, it’s not FDA-approved for weight loss.
Many doctors are willing to prescribe Ozempic off-label for weight loss, but insurance companies typically don’t cover medications prescribed for non-approved uses.
Unfortunately, many insurance plans will not cover weight loss treatments. Under the Affordable Care Act, insurance plans must offer obesity screening and counseling. They are not, however, required to cover treatment options.
If your insurance plan does cover weight loss medications, it will likely require the treatment to be considered medically necessary and you will need to meet certain criteria for eligibility.
Which insurance covers Ozempic for weight loss?
There is no list of insurance companies willing to cover Ozempic for off-label use. Coverage will depend on each company’s policy as well as the specific diagnosis and individual plan.
Each insurance plan will have a prescription “formulary” that lists eligible medications and whether or not they have specific eligibility requirements.
How to get insurance to cover Ozempic: step-by step guide
When it comes to Ozempic insurance coverage, you have two options:
- Shop around for a new insurance plan that offers coverage
- Attempt to secure coverage through your current plan
1. Finding Insurance that Covers Ozempic
If you have the ability to shop around for new insurance, you’ll want to follow these steps:
- Research Insurance Providers: Look for insurance companies that offer the coverage to meet all your needs.
- Review Plan Details: Check the coverage details of each plan, specifically looking for policies that include coverage for weight loss medications or off-label prescriptions.
- Confirm Coverage with Insurer: Contact the insurance provider to confirm whether Ozempic is covered. Ask about any specific requirements, such as prior authorizations or medical necessity.
- Compare Costs: Evaluate premiums, deductibles, and copays for each plan to find the most affordable option that provides the coverage you need.
- Check Enrollment Periods: Make sure you are within the enrollment window for switching plans, or explore if you qualify for a special enrollment period.
- Switch Plans: Once you’ve found a suitable plan, follow the necessary steps to enroll and confirm your coverage before starting Ozempic.
2. How to get Ozempic covered by insurance
If you don’t have the option to change plans, you can try to negotiate with your current insurance company for coverage. You’ll need to try several different avenues, including:
- Review Your Current Plan: Check your insurance policy to see if there is any coverage for weight loss medications or off-label drug use. Take note of any exclusions or requirements, like prior authorizations.
- Request Prior Authorization: Have your doctor submit a prior authorization request to your insurance company, explaining the medical necessity of Ozempic treatment. You will need to provide medical documentation supporting the use of Ozempic, especially if you have related health conditions like prediabetes.
- Appeal Denials: If your request is denied, don’t give up. File an appeal with your insurance company, providing additional documentation and reinforcing the medical necessity of the medication.
- Explore Alternative Coverage Options: If your appeal is denied, ask your insurance company about other available options, such as discounts or savings programs, that may help reduce costs. You may also want to consider alternatives to Ozempic that may be covered under your current plan.
What to do if I have an Ozempic prescription, but insurance refuses to pay?
If your insurance will not cover Ozempic even after following the above steps, then you will need to consider alternate methods. There are still ways to save on your out-of-pocket costs.
If you are on Medicare or uninsured…
You can apply for Novo Nordisk’s Patient Assistance Program. There are specific eligibility requirements, but if you meet them and are approved you may be able to get Ozempic at no cost to you.
If you are commercially insured…
Novo Nordisk also offers an Ozempic Savings Card to those who are enrolled in a commercial (or private) insurance plan. In order to be eligible, you cannot be enrolled in any government, state, or federally funded medical or prescription benefit programs (including Medicare, Medigap, VA, DOD, TRICARE, or any similar federal or state health care program.)
If approved, you could pay as little as $25 for a 1-, 2-, or 3-month supply for up to 24 months.
Discuss your options with your healthcare provider
Your healthcare provider should be an important part of your health journey. They can help you tailor your plan and find options that suit your needs both medically and financially.
Explore your options and speak with a doctor through Heally.
Sources
- Novo Nordisk: Find out the cost for Ozempic®
- Healthinsurance.org: Does health insurance cover drugs used for weight loss such as Ozempic, Wegovy, Mounjaro, and Zepbound?
- NovoCare: Who can participate in the Patient Assistance Program?
- U.S. Department of Health and Human Services: About the Affordable Care Act
Important Medical Information and Disclaimers
MEDICAL DISCLAIMER: This article provides educational information and does not give medical advice. Ozempic (semaglutide) treats type 2 diabetes with FDA approval, and Wegovy (semaglutide) treats chronic weight management with FDA approval. Consult a qualified healthcare professional before you start or switch medications.
INDIVIDUAL RESULTS VARY: Insurance coverage, drug cost, and clinical outcomes differ. Plan rules, geographic location, pharmacy pricing, and personal health conditions all affect these factors.
SAFETY INFORMATION: Common side effects include nausea, vomiting, diarrhea, constipation, abdominal pain, decreased appetite, headache, and fatigue. Serious risks may include pancreatitis, gallbladder disease, acute kidney injury, and severe gastrointestinal issues. The FDA requires a boxed warning about thyroid C‑cell tumors. People with a personal or family history of medullary thyroid carcinoma or MEN 2 should not use semaglutide.
COMPOUNDED PRODUCTS WARNING: The FDA cautions that compounded semaglutide has not been evaluated for safety, efficacy, or quality and should not replace FDA‑approved medication.
FDA ADVERSE‑EVENT REPORTING: Report suspected side effects to MedWatch at 1‑800‑FDA‑1088 or www.fda.gov/medwatch.
