Is Ozempic Covered by Insurance?

Diabetes is a growing health crisis, with predictions that by 2060, around 526,000 young people will have type 1 or type 2 diabetes. Managing diabetes is vital, but the financial burden is significant. In the US, diabetes care already takes up a large share of healthcare costs, reaching $412.9 billion in 2022, with direct medical costs being a major factor.

Ozempic, an effective medication for type 2 diabetes, is another costly treatment, making it inaccessible for many patients. Without financial aid, many patients can’t afford essential drugs like Ozempic, leading to skipped doses or stopping treatment altogether.

This article explores whether Ozempic is covered by insurance and strategies to reduce its cost, including understanding insurance details, using patient assistance programs, and finding alternative options.

How Much Is Ozempic Without Insurance?

The cost of a one-month supply of Ozempic (semaglutide) varies significantly depending on whether you have insurance. Ozempic’s cost without insurance is $968.52 per month. To understand how the price can vary, here are some prices from several pharmacies across the US, according to GoodRx data.

Ozempic prices are significantly lower in Canadian mail-order pharmacies than in the US. For instance, at Pharma Giant, a one-month supply of Ozempic costs only $419. For the amount you would spend on a one-month supply in the US, you could buy two months’ worth of Ozempic from Pharma Giant.

How Much Is Ozempic With Insurance?

The cost can be much lower for those with insurance in the US. Many commercial insurance plans cover Ozempic, and with the use of a savings card provided by the manufacturer, Novo Nordisk, eligible patients can reduce their out-of-pocket costs to as little as $25 per month. This savings card offers a maximum of $150 off per one-month supply, $300 off for a two-month supply, and $450 off for a three-month supply?.

However, it’s important to note that this $25 monthly cost is typically only available to those with commercial insurance and does not apply to those on government-sponsored health plans like Medicare or Medicaid. You may still get some coverage if you are enrolled in one of these programs, but the exact cost will depend on your specific plan’s details.

Did You Know

Sen. Bernie Sanders, Chairman of the Senate Health, Education, Labor, and Pensions (HELP) Committee, initiated an investigation into the price of Ozempic. The Senate committee is asking Novo Nordisk to explain why Ozempic costs so much more in the US than in other countries.

This investigation follows a 2024 study revealing that the cost of manufacturing GLP1 RAs, like Ozempic, only ranges from $0.75 to $72.49 per month. The committee is particularly interested in whether Novo Nordisk can “substantially reduce” the price for American patients.

Is Ozempic Covered by Insurance?

Yes, Ozempic is often covered by insurance, but the extent of coverage varies depending on the specific insurance plan and the indication for which it is prescribed.

Types of Ozempic Insurance Coverage

Insurance coverage for Ozempic can vary depending on the specific insurance plan and provider. Typically, Ozempic may be covered under prescription drug benefits within health insurance plans. Here are two types of insurance coverage for Ozempic:

1. Commercial Health Insurance

Most private insurance plans generally cover Ozempic for managing type 2 diabetes, as this is its FDA-approved use. It falls under the category of antidiabetic medications. Since Ozempic is not FDA-approved specifically for weight loss, coverage for weight loss is less consistent. The cost of Ozempic with insurance for diabetes treatment can vary based on several factors:

• Formulary
• Network pharmacy
• Quantity limits
• State of residence
• Any deductibles or copays

Moreover, some insurance plans may require a healthcare provider to obtain prior authorization before covering the medication. So, what insurance covers Ozempic?

Here are some of the most well-known insurance providers and their coverage for Ozempic. However, please note that insurance coverage can vary over time and across different plans. It’s best to contact your insurance provider directly for a clearer understanding of your coverage:

Aetna

Ozempic is covered by Aetna insurance, but specific criteria must be met. According to Aetna’s website, these criteria include:

• The patient must have been receiving GLP-1 agonist therapy (e.g., Adlyxin, Bydureon, Byetta, Ozempic, Tanzeum, Trulicity, Victoza) for ?3 months and have shown A1c reduction since starting; or

• The patient must have a diagnosis of type 2 diabetes and either:

• Experienced inadequate treatment response, intolerance, or contraindication to metformin therapy; or
• Require combination therapy and have an A1c (hemoglobin A1c) ? 7.5%.

As for Aetna’s quantity limits, coverage for additional quantities beyond the FDA’s recommended dosing can be reviewed case-by-case upon request. The limit for a 0.25 or 0.5 mg dose of Ozempic is 1 pen per month, while that of a 1.0 mg dose is 2 pens per month.

Additionally, under Aetna plans, Ozempic is subject to step therapy, which is a utilization management tool used by insurance companies to control prescription drug costs. Step therapy, also known as a “fail first” protocol, requires patients to try one or more less expensive medications before “stepping up” to costlier medications like Ozempic.

Specifically for Ozempic, patients must have a documented contraindication, intolerance, allergy, or failure after one month of treatment with Metformin/Metformin XR before being approved for Ozempic.

Overall, the estimated duration of approval for Ozempic coverage under Aetna is 12 months.

Humana

Humana does cover Ozempic, although there is limited information available regarding specific coverage details under Humana plans. According to their website, Ozempic is included in their list of medically accepted GLP-1 medications, but weight loss is excluded from coverage.

According to Humana’s formulary, Ozempic is classified under Tier 3. The higher the tier, the more you have to pay for the medication, and Humana has 5 tiers. Additionally, Ozempic does not require prior authorization or step therapy and is available through mail-order services.

Regarding quantity limits, the allowance for Ozempic is as follows:

• 0.25 mg or 0.5 mg dose: 1.5 pens per 28 days.
• 1.0 mg dose: 3 pens per 28 days.

Always refer to your specific plan documents or contact Humana for the most accurate and up-to-date information.

Blue Cross Blue Shield (BCBS)

Ozempic is covered by Blue Cross Blue Shield (BCBS). However, it’s important to note that BCBS is a network of 33 independent licensees, including Anthem and Empire, each with its own policies. As a result, coverage for Ozempic can vary, some licensees may cover it, while others may not.

For example, Anthem Blue Cross (Anthem) will only cover Ozempic if its use is clinically appropriate and aligns with FDA prescribing guidelines. Coverage requests for Ozempic may be approved based on the following criteria:

• The individual has a diagnosis of type 2 diabetes; and
• Written documentation confirms the diagnosis, verified by one of the following:

• Hemoglobin A1c (A1C) greater than or equal to 6.5%; or
• Fasting Plasma Glucose (FPG) greater than or equal to 126 mg/dL (after fasting for at least 8 hours); or
• Two-hour plasma glucose greater than or equal to 200 mg/dL during an oral glucose tolerance test (75g oral glucose after fasting for at least 8 hours); or
• Symptoms of hyperglycemia (such as polyuria, polydipsia, polyphagia) or hyperglycemic crisis and random plasma glucose greater than or equal to 200 mg/dL.

Given the variability in coverage among BCBS licensees, check with your provider to understand the terms of Ozempic coverage.

Kaiser Permanente

Ozempic is covered by Kaiser Permanente when the following criteria are met:

• No personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).
• Using metformin at its maximum tolerated dosage or experiencing intolerance or contraindication to metformin (including both immediate-release and extended-release formulations).
• The target HbA1c level was not achieved after a sufficient trial of an SGLT-2 inhibitor such as Jardiance.
• Meets one of these conditions:

• The latest A1c falls above but within 2% of the patient’s target level.
• The latest A1c exceeds the patient’s target, and they use insulin at a daily dose equal to or greater than 0.5 units/kg/day.
• Has a contraindication to or cannot tolerate the maximum dose of sulfonylurea and any dose of pioglitazone for at least 3 months.
• Is using insulin at a total daily dose equal to or greater than 0.5 units/kg/day and did not reach the A1c goal after an adequate trial of pioglitazone, unless there is intolerance or contraindication.

Kaiser Permanente provides different coverage options for various situations, including those already taking the medication and those using Ozempic for cardiovascular risk reduction.

United Healthcare

Ozempic is covered by United Healthcare. According to their formulary, Ozempic is categorized under Tier 3. Prior authorization and step therapy are required. Additionally, the quantity limit for Ozempic is 1 pen per 28 days for all doses.

2. Public Health Insurance Programs

These programs are established and administered by the government to provide health coverage to specific groups of individuals, such as seniors, low-income individuals and families, and military personnel and their families. Here are some examples:

Medicare

Ozempic is covered by Medicare Part D prescription drug plans, which cater to prescription medication needs. In 2022 alone, Ozempic accounted for a gross spending of $4.6 billion under Medicare Part D. Additionally, it might be included in Medicare Advantage plans (Part C) that offer prescription drug coverage (MAPD).

In 2023, there was no maximum limit on how much Medicare Part D beneficiaries could pay for their prescription drugs. Fortunately, the Inflation Reduction Act introduced a maximum out-of-pocket spending cap.

This will mean that you’ll have a limit on the total amount you’ll need to spend out-of-pocket for your prescription medications within a year. In 2024, the maximum amount you’ll pay for your prescription drugs will be $3,333 annually. Then, in 2025, this amount will be further reduced to $2,000 per year.

Coverage details and out-of-pocket expenses can fluctuate based on the individual’s eligibility and the specific plan.

Medicaid

Medicaid, a state-administered program in the US, offers health coverage to qualifying low-income individuals and families. State Medicaid programs typically cover GLP-1 agonists like Ozempic for type 2 diabetes treatment.

Look up your state’s preferred drug list or formulary. Each state has its own list, and how they classify Ozempic varies. For example, North Carolina includes Ozempic as a preferred agent for diabetic beneficiaries, but Wyoming lists it as nonpreferred.

In addition, some Medicaid programs may mandate specific criteria for Ozempic coverage. Besides having type 2 diabetes, you might need to be at least 18 and try other meds like metformin first.

Tricare

Tricare is a US healthcare program that provides comprehensive health coverage to members of the uniformed services, retirees, and their families. It offers a range of healthcare benefits, including medical services, prescription drugs, mental health services, and dental care. The Department of Defense manages Tricare and serves millions of beneficiaries worldwide.

Tricare coverage for Ozempic is non-formulary, which means that Ozempic is not included on Tricare’s list of preferred medications. To be covered, Ozempic requires approval through a coverage review. Your healthcare provider must request this review by submitting a prior authorization. Moreover, if you’re unable to take a preferred alternative, a Medical Necessity Form is also necessary.

Now that we’ve looked at the different insurance providers for Ozempic, let’s discuss how you can obtain insurance approval for this medication.

How To Get Ozempic Covered By Insurance?

Though most insurance providers cover Ozempic for Type 2 diabetes, you may have to prove you have the condition before your plan will pay for the medication. Below are steps you can take to increase the chances of getting Ozempic covered by your insurance:

1. Check your insurance policy

Your insurance company provides a formulary, which is a list of medications they cover. This list often categorizes drugs into different tiers that affect your copayment. For example, generic drugs might be in a lower tier with lower copayments, while brand-name drugs like Ozempic might be in a higher tier with higher costs.

Look for Ozempic in the formulary. Check if it’s listed, and note any specific conditions under which it’s covered, such as step therapy requirements (where you must try other medications first) or prior authorization.

2. Consult your healthcare provider

Discuss your medical history and treatment needs with your provider. They can provide documentation and rationale for why Ozempic is the best choice for your condition. This may include past treatment failures with other medications or specific health considerations that make Ozempic more suitable. Your doctor might also know about other covered medications that can be effective. They can help you weigh the benefits and drawbacks of each option.

3. Prior authorization

Many insurance plans require prior authorization for expensive medications like Ozempic. Prior authorization, also known as preauthorization, is a process used by health insurance companies to evaluate the necessity and cost of certain procedures, tests, and medications before approval.

The processing time can range from one day to a month, depending on the complexity and requirements. According to a 2018 AMA survey, 26% of providers reported waiting three days or more for a decision.

Currently, the process follows these steps:

Step 1: Contact Your Healthcare Provider’s Office

Specifically, you need to speak with the individual responsible for handling prior authorization requests. This person will guide you through the necessary procedures and inform you about what documents and information you need to provide.

Step 2: Complete the Required Forms

Next, you need to fill out specific forms required for the prior authorization process. These forms typically include personal information, details about your medical condition, and the healthcare services or treatments being requested.

It is important to ensure that all information is complete and accurate. One of the main reasons prior authorizations are delayed is the submission of incomplete or incorrect information to the health plan, which results in denials and requires extensive manual rework from the provider.

Step 3: Keep Your Documents Organized

Record all documents submitted and any correspondence related to your request. This documentation is essential for tracking the current request and reference in case future authorizations are needed. Additionally, having organized records can be invaluable if you need to appeal a denied request.

Step 4: Monitor Important Deadlines

Timeliness is another critical factor in the prior authorization process. Be aware of any deadlines for submitting information and ensure that both you and your provider’s office adhere to these timelines. Setting reminders can help you manage these deadlines effectively and prevent any unnecessary delays.

Step 5: Prepare for Potential Denials

It is important to have a plan in place in the event that your prior authorization request is denied. Begin by understanding the reason for the denial. Often, a denial results from simple errors that can be corrected quickly. Verify that all submitted paperwork was complete and accurate.

If necessary, gather additional evidence or documentation supporting the requested service’s medical necessity. This might include research or expert opinions that your provider can help procure. If you believe the denial was unjustified, you can work with your provider to appeal the decision.

Pro Tip

One of the main reasons prior authorizations take so long to resolve is that incomplete or incorrect information is submitted to the health plan, leading to denials and extensive manual rework for the provider. To avoid this, ensure all forms are thoroughly filled out with accurate details.

Additionally, confirm that all required documents and supporting evidence are included. Clear communication with your provider’s office can help verify that everything is in order before submission, reducing the likelihood of errors and subsequent delays.

4. Appeal if necessary

If your initial request for coverage is denied, you have the right to appeal. The denial letter from your insurance company will provide instructions on how to appeal.

Work with your healthcare provider to draft an appeal letter. This letter should include a detailed explanation of your medical condition, the necessity of Ozempic, and any supporting medical evidence or documentation. Include any additional information that addresses the reasons for the denial.

Understand your insurance coverage and any potential out-of-pocket costs associated with obtaining Ozempic or any other medication.

How To Get Ozempic Without Insurance?

Getting Ozempic without insurance can be challenging due to its high price. Here are a few methods that might lower the expense.

1. Buying Ozempic from a Canadian Mail-Order Pharmacy

On Pharma Giant, a Canadian mail-order pharmacy, Ozempic is priced at $419 for a month’s supply, significantly lower than prices at US mail-order pharmacies, which can reach up to $1,200 for the same quantity. Similarly, Victoza, another diabetes medication, costs around $1,000 in the US but only $255 in Pharma Giant.

In addition to lower prices, you can enjoy further discounts and offers when ordering larger quantities. For new customers, Pharma Giant offers 10% off on their first order using the coupon code PGSAVE10.

Furthermore, Pharma Giant promises expedited delivery, with medications typically arriving within 3-5 business days, ensuring timely access to essential treatments.

Did You Know

On January 5, 2024, the FDA granted authorization to Florida to import specific prescription drugs from Canada. This landmark decision follows over three years of efforts by Governor Ron DeSantis and his administration to implement an importation plan.

The FDA’s approval, valid for two years, affirms that the program meets safety standards while offering significant cost savings. Florida estimates potential savings of up to $183 million in the first year, primarily benefiting the state’s Medicaid program.

2. Applying for Novo Nordisk’s Patient Assistance Program (PAP)

Novo Nordisk provides assistance programs for patients to afford their medications, particularly aiding those who are uninsured or underinsured. Two of their semaglutide products, Ozempic and Rybelsus, are included in this program for coverage eligibility.

Eligibility Criteria

To qualify for the program, you must meet the following:

• Must be a US resident
• Must have a total household income at or below 400% of the federal poverty level (FPL)
• Must be either without insurance or covered by Medicare
• Not eligible for other federal, state, or government programs such as Medicaid, Low Income Subsidy, or Veterans Affairs (VA) Benefits

Your healthcare provider will receive an email copy of your application and must complete specific sections.

Application Process

To apply for Novo Nordisk’s Patient Assistance Program:

Step 1: Download and fill out the application form

Download the PAP Application Form or request a copy from your healthcare provider.

Step 2: Gather proof of income

Provide proof of your household’s adjusted gross annual income. Make copies of one of the following documents:

• Two of the most recent paycheck stubs or earning statements for all working members of your household
• Individual Income Tax Return (1040) of the previous year
• Statements showing Social Security income, pension, or other sources of income
• W-2 or 1099 forms
• Unemployment benefit statements

Step 3: Complete the application

Once you’ve gathered the necessary documents, take the completed application and proof of income to your healthcare provider. Ask your provider to:

• Complete the sections related to the Prescriber and Prescription on the application form
• Sign the application
• Either fax the completed application and proof of income to 1-866-441-4190, or mail them to Novo Nordisk Inc., PO Box 370, Somerville, NJ 08876. Note that faxes must be sent from the healthcare provider’s office.

Once you submit the application, allow up to 10 business days for processing. Novo Nordisk will review your application and inform you and your healthcare provider of the decision. If your application is approved, the medication will be sent to your healthcare provider’s office at no cost.

Final Thoughts

The cost of Ozempic can vary significantly depending on factors such as insurance coverage, pharmacy location, and eligibility for assistance programs. Without insurance, the list price can be over $900 monthly, but prices may be lower at Canadian mail-order pharmacies.

For uninsured or underinsured individuals, patient assistance programs offered by the manufacturer, Novo Nordisk, can provide access to Ozempic at no cost for those who meet income eligibility criteria.

Despite the challenges with Ozempic’s insurance coverage denials, other avenues are available to make Ozempic more affordable for those who need it.

Frequently Asked Questions