Is Ozempic (Semaglutide) Covered By Insurance? Everything You Need to Know About Costs and Coverage

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Of the more than 37 million Americans living with some form of diabetes, the vast majority of them have Type 2 diabetes. Ozempic (semaglutide), a prescription medication administered through injections, is FDA-approved to help adults with Type 2 diabetes manage their blood glucose (sugar) levels. It can also lower the risk of major cardiovascular events in certain people.

Most health insurance providers cover Ozempic when it's being used to treat Type 2 diabetes. However, there may still be out-of-pocket costs, including deductibles, copays, and coinsurance, depending on the plan.

Healthcare professionals may also prescribe Ozempic off-label to help people without diabetes lose weight, but the medication is not FDA-approved for this purpose. As a result, many health insurance companies won't cover Ozempic for chronic weight management.

What is Ozempic?

Ozempic is classified as a glucagon-like peptide-1 (GLP-1) agonist, a type of medication that imitates the actions of a gut hormone known as GLP-1. Ozempic works by reducing blood glucose levels following meals and reducing glucose production in the liver. It also slows the movement of food out of the stomach.

GLP-1 is believed to directly impact the area of the brain that regulates appetite. So, by acting like GLP-1, Ozempic can also affect appetite and make you feel full. This can reduce calorie intake, resulting in weight loss.

How much does Ozempic cost with and without insurance?

The list price for Ozempic is approximately $968 per injection pen without insurance. But most people pay the retail price and not the list price. On average, the retail price for an Ozempic injection pen ranges anywhere from $1,000 to $1,200 or more, depending on the pharmacy you visit.

The cost of Ozempic can be affected by many factors, including:

• Your location

• Pharmacy you choose

• Dosage you're prescribed

• Your insurance coverage

• Your eligibility for patient assistance programs

Since Ozempic is intended for long-term use, the costs can add up over time. And a generic version doesn't exist, so Ozempic prices have remained high. But you can save money by using a GoodRx coupon and manufacturer discounts, if you're eligible.

Does my health insurance plan cover Ozempic?

Whether your insurance covers Ozempic depends on your plan and medical condition. For example, your insurance may cover the medication if you have Type 2 diabetes, but you may have a copay or other out-of-pocket costs based on your plan.

However, your insurance may not cover Ozempic at all if you don't have diabetes and you're taking it for an off-label use, such as weight loss or polycystic ovary syndrome (PCOS). Most plans only pay for costs associated with weight-related health problems once the problems develop - not weight-loss treatments to prevent health issues from occurring.

Below, read about how various insurance providers approach coverage for Ozempic.

Private or employer-sponsored insurance

In general, weight-loss medications are not widely covered by employer-sponsored plans in the U.S. Private insurance plans are only required to cover obesity screening and counseling under the Affordable Care Act's (ACA, also known as Obamacare) essential health benefits.

Even if your insurer covers a specific medication for weight loss, such as Ozempic, you may have to meet certain criteria for the medication to be considered medically necessary, such as having a minimum body mass index (BMI) and making behavioral modifications.

Novo Nordisk, the manufacturer of Ozempic, has an online tool to help determine the cost of Ozempic with your insurance plan. A representative will review your benefits and give you an estimate over the phone or online. But you must have your prescription insurance card details available to get assistance.

If you have private or commercial insurance, you may be able to pay as little as $25 for a 1-, 2-, or 3-month supply of Ozempic with the help of a savings card. This offer is valid for up to 24 months and could lead to savings of up to $150 on a 1-month prescription, $300 on a 2-month prescription, or $450 on a 3-month prescription of Ozempic.

Medicare

Medicare insures people who are 65 or older, certain younger people with disabilities, and individuals with end-stage renal disease. Medicare Part D covers a variety of diabetes medications. So if you have Medicare, check the details of your prescription medication coverage to see if Ozempic is covered. With Medicare Advantage plans, most policies include Medicare Part D prescription medication coverage.

However, Medicare doesn't cover medications used solely for weight loss. Congress prohibited the program from covering obesity treatments as part of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA).

Medicaid

Medicaid provides health coverage to more than 77 million Americans, including children, pregnant women, low-income families, and people with disabilities. All states currently offer outpatient prescription medication coverage as part of their Medicaid programs. However, each state has its own rules and requirements around prior authorizations, step therapy, quantity limits and other coverage details. Contact your state's Medicaid agency for details about your plan and whether Ozempic is covered.

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 four steps to increase your chances of getting Ozempic covered by your insurance provider:

1. Review your health insurance plan. Reach out to your insurance provider to get a better understanding of what's covered by your plan. You can also review your plan's formulary to see if Ozempic is listed as a covered medication.

2. Get a prescription. Ozempic is a prescription-only medication for adults with Type 2 diabetes. Schedule an appointment with your prescriber to discuss your medical condition, the potential benefits of Ozempic, and the possibility of getting a prescription.

3. Obtain prior authorization, if needed. If your insurance company requires prior authorization for Ozempic, your prescriber may need to provide confirmation that you have Type 2 diabetes and that the medication is medically necessary for treatment.

4. Request an appeal, if necessary. If your insurance provider denies your initial request for coverage, you may appeal to reverse the decision. Review your health insurance plan details and the reason for the denial, so that you can write a solid appeal letter.

Can you get Ozempic for free?

Yes. You can obtain some medications at no cost through the Novo Nordisk Patient Assistance Program, if you qualify. More than a dozen medications are on the list of covered products, including Ozempic. To be eligible for the program, you must meet several requirements, including:

• Being a U.S. citizen or legal resident

• Falling below a certain income level

• Having Medicare or not having insurance

You can apply for the patient assistance program online.

Ozempic alternatives

Although there is not a generic version of Ozempic on the market, there are alternative medications for managing Type 2 diabetes. There are also FDA-approved medications for weight loss. The following table includes some of these medications and their FDA-approved uses.

Whether these Ozempic alternatives are covered and, if so, how much of the cost is covered depends on your insurance plan and provider. For example, even if your policy covers weight-loss medications, it may only pay for specific ones. And there could be a high copay or the need for a prior authorization, depending on the medication.

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GoodRx Holdings Inc. published this content on 09 July 2024 and is solely responsible for the information contained therein. Distributed by Public, unedited and unaltered, on 09 July 2024 19:41:38 UTC.