Does Insurance Cover Ozempic? Wondering if your insurance covers Ozempic? You’re not alone. Many people are curious about whether this effective diabetes medication is included in their plan.
Ozempic, a once-weekly injectable, is designed to help manage blood sugar levels in adults with type 2 diabetes. It works by mimicking a hormone that regulates blood sugar, offering benefits like improved glycemic control and potential weight loss.
Given its growing popularity, understanding your insurance coverage is key to managing costs and ensuring access to this important treatment.
In this blog, we’ll delve into the specifics of how insurance plans typically cover Ozempic, a widely prescribed medication for type 2 diabetes.
What Is Ozempic And How Does It Work?
Ozempic is a type of medication known as a glucagon-like peptide-1 (GLP-1) agonist, which mimics the function of the GLP-1 hormone produced in the gut.
It lowers blood sugar levels after eating and reduces glucose production by the liver. Additionally, Ozempic slows down the digestion process by delaying the stomach’s emptying.
GLP-1 is thought to play a role in controlling appetite by acting on a specific area of the brain. By imitating GLP-1, Ozempic can help curb appetite and promote a sense of fullness, leading to reduced calorie intake and potential weight loss.
How Much Does Ozempic Cost With And Without Insurance?
You can purchase Ozempic without insurance for approximately $968 per injection pen. However, many people end up paying more than the listed price, with retail costs ranging from $1,000 to $1,200 or even higher, depending on various factors.
However, it’s important to note that this average price may not reflect the actual cost you will pay for Ozempic. The price can vary based on:
- Your location.
- Your preferred pharmacy.
- The prescribed dosage.
- Your insurance coverage.
- Eligibility for patient assistance programs.
Also, since Ozempic is for long-term use, overtime, the cost can add up. And since there’s no generic version, the prices remain high.
Does My Health Insurance Plan Cover Ozempic?
Whether or not your insurance covers Ozempic depends on your specific plan and medical condition. However, insurance may cover the medication if you have Type 2 diabetes, but you might still face a copay or other out-of-pocket expenses, depending on your plan.
On the other hand, if you are using Ozempic for off-label purposes, such as weight loss or treating polycystic ovary syndrome (PCOS), your insurance may not cover it at all.
Most insurance plans cover treatments for weight-related health issues only after they have developed, rather than for weight-loss treatments aimed at preventing these problems.
What Is Ozempic Approved For?
Ozempic is FDA-approved for adults with type 2 diabetes to help lower blood sugar levels in conjunction with diet and exercise. It is also approved to reduce the risk of serious cardiovascular events, such as heart attack, heart disease, and stroke.
This medication is administered as once-weekly subcutaneous injections, which involve using a needle to inject the medicine under the skin in your abdomen, thigh, or upper arm. Your healthcare provider will provide instructions on how to properly use this medication.
Is Ozempic Covered For Weight Loss?
Many insurance companies giving coverage for this only give it when it’s meant to treat type 2 diabetes and not for the purpose of weight loss.
Meanwhile, the ozempic use for weight loss is known or referred to as “off-label” but is not approved by the FDA, so insurance companies may not pay for it.
However, if it is prescribed by your doctor for weight loss and your insurance doesn’t cover it, there are other options you can consider. That include:
- Wegovy: This medication, similar to Ozempic, is an injectable drug approved for weight loss but in a higher dose. Another option is Saxenda, which is also similar to Wegovy and Ozempic.
- Check with your prescription plan to see if any weight loss medications prescribed by your doctor are covered.
Also, your insurance may cover programs for nutrition, exercise planning, and behavioral change.
Does Private Insurance Cover Ozempic?
Most private insurance companies cover Ozempic for type 2 diabetes. But coverage and costs can vary by plan and may change over time.
When you call your insurance company, ask about Ozempic’s tier and your copay, as this depends on your plan.
Also, check if it’s covered for type 2 diabetes and/or weight loss. Insurance plans typically have 4 or 5 tiers, with costs ranging from the lowest (Tier 1) to the highest (Tier 4 or 5).
You can also find your insurance company’s drug formulary on their website, which lists covered drugs and their tiers.
However, if you have questions, contact your insurance company directly. Your pharmacist can also provide information about your copay and suggest alternatives if needed.
Also, keep in mind that even with insurance, you might still pay a significant portion of the cost.
Is Ozempic Covered By Medicare and Medicaid?
Medicare covers diabetes medications through Part D, so if you have Medicare, check if Ozempic is part of your plan. Most Medicare Advantage plans also cover Part D. However, Medicare does not cover medications used only for weight loss due to restrictions set by the Medicare Prescription Drug, Improvement, and Modernization Act.
While Medicaid, on the other hand, provides prescription medication coverage in all states. Coverage details, including prior authorizations and limits, vary by state. So, you should contact your state’s Medicaid office to find out if Ozempic is under your plan.
How To Get Ozempic Covered By Health Insurance
To get Ozempic coverage from your health insurance, follow these steps:
- Check Your Insurance Plan: Review your plan’s formulary (list of covered drugs) to see if Ozempic is there and its tier, which affects your cost.
- Contact Your Insurance Provider: Call your insurance company to confirm coverage for Ozempic. Ask about the copay, any deductibles, and whether coverage includes type 2 diabetes and/or weight loss.
- Ask About Prior Authorization: Find out if you need prior authorization from your insurance company for Ozempic. This means your doctor may need to provide additional information to justify the medication.
- Consult Your Doctor: Work with your healthcare provider to ensure Ozempic is the right treatment for you and to complete any necessary paperwork for prior authorization.
- Explore Patient Assistance Programs: If your insurance doesn’t cover Ozempic or if you face high costs, check if the manufacturer offers patient assistance programs or discounts.
Lastly, consider reviewing alternative options. If Ozempic isn’t part of your coverage options or is too expensive, discuss other medications or treatments with your doctor that might be part of your insurance.