Medicare's Coverage of Ozempic for Type 2 Diabetes

Medicare Part D covers Ozempic (semaglutide) for type 2 diabetes, but whether you pay a small copay or a larger share depends on which plan you chose and which tier the drug sits on. Most plans place Ozempic on a higher tier because it is a newer injectable medication, which usually means a copay of $35 to $75 per month, though some plans charge more. A few plans may not cover it at all, or may require you to try and fail a cheaper diabetes drug first — a step called prior authorization.

Your actual cost also depends on whether you have reached your deductible and whether you have entered the coverage gap (the "donut hole"). If you have not met your deductible, you may pay the full price of Ozempic until you do. Once you are in the coverage gap, you pay a larger percentage of the cost. After you spend enough out of pocket to reach the catastrophic coverage threshold, Medicare pays most of the cost for the rest of the year.

The easiest way to find out what your specific plan covers is to call the customer service number on the back of your Medicare card or log into your plan's website and search for Ozempic by its generic name, semaglutide. Have your plan name and member ID ready.

Key Takeaways

  • Medicare Part D covers Ozempic for type 2 diabetes, but your copay depends on which plan you chose and what tier the drug is on.
  • Most plans place Ozempic on a higher tier, usually resulting in a copay between $35 and $75 per month, though some plans charge more.
  • Your plan may require prior authorization, meaning your doctor must show that you tried a cheaper medication first before Ozempic is covered.
  • Your total cost changes if you have not met your deductible, are in the coverage gap, or have reached catastrophic coverage.
  • You can find your plan's exact coverage by calling the number on your Medicare card or checking your plan's website.

How Medicare Part D Tiers Affect Your Ozempic Cost

Medicare Part D plans organize drugs into tiers, and the tier determines how much you pay. Tier 1 drugs (generics) have the lowest copay, usually $5 to $10. Tier 2 drugs (preferred brand-name) cost more, typically $15 to $35. Tier 3 and Tier 4 drugs (non-preferred brand-name and specialty drugs) have the highest copays, often $50 to $100 or more per month.

Ozempic is almost always placed on Tier 3 or Tier 4 because it is a newer, brand-name injectable. Some plans may offer a generic version, tirzepatide (Mounjaro), on a lower tier, but this is less common. Your plan's formulary — the official list of covered drugs — tells you exactly which tier Ozempic is on and what your copay will be.

If your copay is too high, ask your doctor whether a lower-tier diabetes medication might work for you. Metformin (a generic pill) is usually Tier 1, and some older injectable insulins are on lower tiers than Ozempic. Your doctor can help you weigh the benefits and drawbacks of switching.

Prior Authorization and Step Therapy Requirements

Some Medicare Part D plans require prior authorization before they will cover Ozempic. This means your doctor must contact the plan and explain why Ozempic is medically necessary for you. The plan then approves or denies the request, usually within a few business days.

Other plans use step therapy, which requires you to try and fail a cheaper diabetes medication first — often metformin or another oral drug — before the plan will cover Ozempic. This can delay your treatment by weeks or months. If your doctor believes Ozempic is the right choice for you from the start, they can request an exception, but the plan is not required to grant it.

Before your doctor prescribes Ozempic, ask them to check with your Medicare plan about these requirements. If your plan denies coverage, your doctor can appeal the decision or request a coverage exception based on your medical history.

The Coverage Gap and Catastrophic Coverage

Once you and your plan have paid a combined $5,380 in 2024 (this amount changes each year), you enter the coverage gap. In the gap, you pay 25 percent of the cost of brand-name drugs like Ozempic, while Medicare and your plan pay the rest. This sounds better than it is: 25 percent of Ozempic's full price can still be $100 to $150 per month.

Once your out-of-pocket costs reach $7,550 in 2024, you enter catastrophic coverage. At that point, Medicare pays 80 percent of the cost and you pay 20 percent, or you pay a small copay — whichever is less. For most people, this means a copay of $5 to $10 for the rest of the year.

If you take Ozempic year-round, you may reach catastrophic coverage by late fall or early winter. Keep track of your out-of-pocket spending so you know when you will cross into catastrophic coverage, because your costs will drop sharply.

Other Diabetes Medications Medicare Part D Covers

If Ozempic is too expensive or not covered by your plan, Medicare Part D covers many other diabetes medications. Metformin, the most commonly prescribed diabetes drug, is a generic pill on Tier 1 with a copay of $5 to $10. Sulfonylureas like glyburide are also generic and low-cost. Thiazolidinediones like pioglitazone are generic and usually on Tier 1 or Tier 2.

Newer injectable medications like Trulicity (dulaglutide) and Victoza (liraglutide) are also covered, usually on Tier 3 or Tier 4 like Ozempic. Insulin is covered, though the copay varies by type and brand. GLP-1 receptor agonists — the drug class that includes Ozempic — have several options at different price points.

Your doctor can help you understand which medications are covered by your plan and which might work best for your diabetes. If cost is a barrier, tell your doctor; they may be able to switch you to a lower-tier drug or help you find a patient information program run by the drug manufacturer.

Using Manufacturer Coupons and Patient information Programs

Novo Nordisk, the company that makes Ozempic, offers a savings card that can lower your copay to as little as $25 per month if you have commercial insurance. However, this card does not work with Medicare Part D — federal law prohibits manufacturers from offering discounts on drugs covered by Medicare.

Novo Nordisk does run a patient information program for people with Medicare who cannot afford Ozempic. You can call 1-844-NOVO-777 to ask about the program and whether you may be able to receive Ozempic at no cost. may be able to access depends on your income and whether you have other insurance.

Some pharmaceutical companies also offer copay cards or information programs for other diabetes drugs. Ask your doctor or pharmacist whether the medication they are prescribing has a patient information program, and whether you meet the income requirements.

Switching Plans to Lower Your Ozempic Cost

If your current Medicare Part D plan places Ozempic on a high tier or requires prior authorization, you can switch to a different plan during the Annual Enrollment Period, which runs from October 15 to December 7 each year. The change takes effect on January 1.

Before you switch, compare the formularies of plans available in your area. Use the Medicare Plan Finder tool on Medicare.gov to see which plans cover Ozempic and what the copay is. You can also enter your medications and see the estimated yearly cost for each plan. Some plans may cover Ozempic on Tier 2 or with a lower copay than your current plan.

Keep in mind that switching plans also changes your coverage for other medications and your doctor's network. Make sure any new plan covers your other prescriptions and includes your doctors before you switch.

Frequently Asked Questions

Does Medicare Part B cover Ozempic?

No. Medicare Part B covers injectable drugs that are administered in a doctor's office or hospital, but Ozempic is a self-injected medication that you use at home. Part B does not cover it. Only Medicare Part D (prescription drug coverage) covers Ozempic.

What if my doctor says I need Ozempic but my plan denies it?

Your doctor can file an appeal or request a coverage exception. The plan must respond within 72 hours. If the plan denies the appeal, you can file a grievance with Medicare. Your doctor can also help you find a lower-cost alternative or contact the drug manufacturer about a patient information program.

Will my Ozempic copay change if I switch from Part D to a Medicare Advantage plan?

Yes. Medicare Advantage plans (Part C) include prescription drug coverage, but the formularies and copays are different from Part D plans. Some Advantage plans may cover Ozempic on a lower tier, while others may not cover it at all. Compare the formularies before you switch.

Can I use a GoodRx coupon with Medicare Part D?

No. Federal law prohibits using discount cards or coupons with Medicare Part D. You must use your Medicare coverage. However, you can ask your pharmacist to price Ozempic without insurance to see if paying out of pocket is cheaper than your copay — this is rare, but it happens with very expensive drugs.

Does Medicare cover Ozempic for weight loss?

No. Medicare Part D covers Ozempic only when it is prescribed for type 2 diabetes. If your doctor prescribes it for weight loss alone, Medicare will not cover it, even if you have a Part D plan. Wegovy, the brand-name version of semaglutide marketed for weight loss, is also not covered by Medicare.