Medicare covers Ozempic through Part D prescription drug plans, but only if your doctor prescribes it for type 2 diabetes — not for weight loss alone. Your out-of-pocket cost depends on which plan you chose and what stage of the benefit year you are in. Most plans require you to try other diabetes medications first, a step called a prior authorization, before they will pay for Ozempic.
Key Takeaways
- Ozempic is covered by Medicare Part D plans when prescribed for type 2 diabetes, but coverage rules and costs vary by plan.
- Your plan may require prior authorization, meaning your doctor must show that you have tried other medications first or have a medical reason why Ozempic is necessary.
- You pay different amounts depending on which stage of the benefit year you are in: the deductible stage, the initial coverage stage, the coverage gap, or catastrophic coverage.
- If your plan does not cover Ozempic or the cost is too high, you can switch to a different Part D plan during the annual open enrollment period in October and November.
- Manufacturer discounts and patient information programs may lower your cost if you meet income requirements.
What Medicare Part D Plans Cover for Ozempic
Medicare Part D is the prescription drug benefit, and it covers Ozempic when a doctor prescribes it to treat type 2 diabetes. However, not every Part D plan covers it the same way. Some plans put Ozempic on their formulary — the official list of drugs they will pay for — while others do not. Even plans that do cover it may charge different copays or coinsurance amounts, and some may require you to pay a higher percentage of the cost.
The first step is to check your specific plan's formulary. You can find this on your plan's website or by calling the customer service number on your Medicare card. When you call or search online, ask whether Ozempic is on the formulary and what your out-of-pocket cost would be. If it is not covered, you have the option to switch plans during the annual open enrollment period, which runs from October 15 to December 7 each year.
Prior Authorization and Step Therapy Requirements
Many Medicare Part D plans require prior authorization before they will pay for Ozempic. This means your doctor must submit a request to the plan explaining why you need this medication. The plan reviews the request and decides whether to approve it. This process usually takes a few business days, though it can take longer if the plan asks for more information.
Some plans also use step therapy, which means you must try and fail on other diabetes medications first — usually metformin or other oral medications — before the plan will cover Ozempic. Your doctor can request an exception if there is a medical reason you cannot take those other drugs, such as a severe side effect or kidney problems. If the plan denies the exception, your doctor can appeal the decision.
Ask your doctor's office to handle the prior authorization request. They have the forms and know how to submit them to your plan. If the plan denies coverage, your doctor can file an appeal on your behalf, and you have the right to request an independent review if you disagree with the plan's decision.
How Your Costs Change Throughout the Year
Medicare Part D divides the benefit year into four stages, and your out-of-pocket cost for Ozempic changes at each stage. Understanding where you are in the year helps you predict what you will owe.
| Stage | What Happens | Your Cost |
|---|---|---|
| Deductible | You have not yet met your plan's deductible amount. | You pay the full price of Ozempic until you reach your deductible (usually $505 to $550 in 2024, but this varies by plan). |
| Initial Coverage | You have met your deductible and are in the main coverage period. | You pay a copay (a fixed amount like $15 or $35) or coinsurance (a percentage like 20 percent of the cost). |
| Coverage Gap | Your total drug costs have reached a certain threshold (around $5,030 in 2024). | You pay 25 percent of the cost of Ozempic. Medicare and the drug maker also pay, but you are responsible for your 25 percent share. |
| Catastrophic Coverage | Your out-of-pocket costs have reached the catastrophic threshold (around $7,050 in 2024). | You pay a small copay (usually $5 to $10) or coinsurance (5 percent), and Medicare pays the rest. |
Once you reach catastrophic coverage, your costs stay low for the rest of the year. If you take Ozempic regularly, you may reach this stage by late fall or early winter, depending on when you started the medication and how much it costs under your plan.
Manufacturer Discounts 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 or Medicare Part D coverage. You can find this card on the Novo Nordisk website or ask your pharmacy about it. The card works at most major pharmacies, including CVS, Walgreens, and Walmart.
Novo Nordisk also runs a patient information program for people who cannot afford their medications. This program may provide Ozempic at no cost if your household income falls below certain limits. You can learn more and request information through the Novo Nordisk website or by calling their patient information line. Your doctor's office can also help you find and explore for these programs.
What to Do If Your Plan Does Not Cover Ozempic
If your current Part D plan does not cover Ozempic, or if the cost is too high, you can switch to a different plan. The annual open enrollment period runs from October 15 to December 7 each year. During this time, you can change your Part D plan, and the new coverage starts on January 1.
To find a plan that covers Ozempic at a lower cost, use the Medicare Plan Finder tool on Medicare.gov. Enter your zip code, and the tool will show you all available Part D plans in your area. You can filter by drug name to see which plans cover Ozempic and what your estimated costs would be under each plan. Compare not just the copay but also the deductible and whether prior authorization is required.
If you miss the annual open enrollment period, you may still be able to switch plans if you have a may have access to life event, such as moving to a new state, losing employer coverage, or becoming newly may be able to access for Medicare. Contact Medicare at 1-800-MEDICARE to ask whether you may have access to for a special enrollment period.
Appealing a Plan Denial
If your plan denies coverage for Ozempic or refuses to pay after you have already started taking it, you have the right to appeal. Your doctor can file an appeal on your behalf, or you can file one yourself. The appeal process has several levels: first a standard review by the plan, then an expedited review if you need a faster decision, and finally an independent review by an outside organization if you disagree with the plan's decision.
Ask your doctor's office or your plan's customer service line for the appeal form and instructions. Include any medical records or letters from your doctor that explain why Ozempic is medically necessary for you. The plan must respond to a standard appeal within 72 hours and to an expedited appeal within 24 hours.
Frequently Asked Questions
Does Medicare cover Ozempic for weight loss?
No. Medicare Part D covers Ozempic only when it is prescribed to treat type 2 diabetes. If your doctor prescribes it for weight loss alone, Medicare will not pay for it. Some people with type 2 diabetes do lose weight while taking Ozempic, but weight loss by itself is not a covered reason under Medicare rules.
What if I cannot afford the copay even with the manufacturer's discount card?
Talk to your doctor about whether a different diabetes medication might work for you, as some alternatives may have lower copays under your plan. You can also ask your doctor's office to help you explore for Novo Nordisk's patient information program, which may provide the medication at no cost if you meet income limits. Your local Area Agency on Aging may also know about other financial information programs in your community.
Can I use GLP-1 drugs like Ozempic if I am on Original Medicare without Part D?
Original Medicare (Parts A and B) does not cover prescription drugs. You must have Part D coverage to get Medicare to help pay for Ozempic. If you do not have Part D, you can enroll during the annual open enrollment period or during a special enrollment period if you have a may have access to life event.
How long does prior authorization take?
Most plans respond to a prior authorization request within 3 to 5 business days. However, if the plan needs more information from your doctor, it can take longer. Ask your doctor's office to follow up with the plan if you do not hear back within a week. In urgent cases, your doctor can request an expedited review, which the plan must complete within 24 hours.
What happens to my Ozempic coverage if I move to a different state?
Your current Part D plan may not be available in your new state. When you move, you have a special enrollment period to switch to a plan available in your new location. Contact Medicare at 1-800-MEDICARE as soon as you know your move date so you can enroll in a new plan before your current coverage ends. Make sure the new plan covers Ozempic before you finalize your choice.