What Medicare covers for Ozempic and what you pay out of pocket

Medicare Part D covers Ozempic, but your out-of-pocket cost depends on which plan you have, which pharmacy you use, and whether your doctor prescribes it for diabetes or weight loss. Most people with Part D pay between $0 and $400 per month, though some pay more. The drug is on the formulary (covered list) of most major plans, but not all — and the tier it sits on determines your copay or coinsurance.

For diabetes, Medicare is more likely to cover the cost fully or at a low copay. For weight loss, coverage is much less common and often requires prior authorization — a written approval from your insurance company before the pharmacy will fill it. Even when covered for weight loss, your copay may be higher.

Your actual cost also shifts depending on which stage of the Part D benefit year you are in. Early in the year, you pay your regular copay. Once you hit the coverage gap (sometimes called the "donut hole"), your costs jump. Once you reach catastrophic coverage, they drop again.

Key Takeaways

  • Most Part D plans cover Ozempic for diabetes at a copay between $0 and $75 per month, though some plans charge coinsurance (a percentage of the cost) instead.
  • For weight loss, coverage is rare and usually requires your doctor to request prior authorization before the pharmacy will fill your prescription.
  • The price you see at the pharmacy changes as you move through the Part D benefit year — your copay is lower early in the year and higher once you enter the coverage gap.
  • Using a GoodRx coupon or manufacturer discount card can sometimes lower your cost below what your insurance charges, even if you have Part D coverage.
  • Your plan's formulary and tier placement can change each year, so the price you paid last year may not be what you pay this year.

How Part D tier placement affects your Ozempic cost

Part D plans organize drugs into tiers, usually four or five levels. Tier 1 drugs (generic, preferred) have the lowest copay. Tier 2 (preferred brand) costs more. Tier 3 (non-preferred brand) costs even more. Tier 4 (specialty) can cost the most — sometimes $250 or more per month.

Ozempic is a brand-name drug, so it sits on Tier 2 or Tier 3 on most plans. A few plans place it on Tier 4. Check your plan's formulary (the official list of covered drugs) on your insurance company's website or call the number on your Medicare card to find out which tier your plan uses. The formulary also tells you whether prior authorization is required.

Some plans offer a lower copay if you use a mail-order pharmacy instead of a retail one. Others offer copay information programs for people who hit their out-of-pocket maximum. Ask your plan directly whether either option applies to you.

The difference between copay and coinsurance

A copay is a fixed dollar amount you pay — for example, $35 per injection or per month's supply. Coinsurance is a percentage of the drug's cost. If your plan charges 20 percent coinsurance and Ozempic costs $1,000, you pay $200.

Most Part D plans use copays for brand-name drugs like Ozempic, but some use coinsurance instead. Coinsurance can be unpredictable because the pharmacy's price for the drug can vary. Before you fill your prescription, ask the pharmacy what your out-of-pocket cost will be — do not assume it is the same as last month.

Prior authorization and step therapy requirements

Many Part D plans require prior authorization for Ozempic, especially when prescribed for weight loss. Prior authorization means your doctor must submit a form to your insurance company explaining why you need the drug. The insurance company then approves or denies the request, usually within a few business days.

Some plans also use step therapy, which means you must try a cheaper drug first (usually metformin for diabetes, or a different weight-loss medication) before the plan will cover Ozempic. If step therapy applies to you, your doctor can request an exception if they believe Ozempic is medically necessary without trying the other drug first.

Do not wait until you are ready to fill your prescription to find out whether prior authorization is needed. Call your insurance company or ask your doctor's office to check before the prescription is written. If authorization is required and your doctor has not submitted it, the pharmacy will reject the prescription and you will have to wait for approval before trying again.

What happens during the coverage gap and catastrophic phase

The Part D benefit year runs January through December. Early in the year, you pay your regular copay or coinsurance. Once your total drug costs (what you and your plan pay combined) reach $5,850 in 2024, you enter the coverage gap. In the gap, you pay 25 percent of the drug's cost yourself, and a manufacturer discount covers another 50 percent. Your plan pays nothing.

Once your out-of-pocket spending reaches $8,550 in 2024, you enter catastrophic coverage. At that point, you pay only 5 percent of the cost, and your plan pays the rest. These dollar amounts change each year — check your plan's summary of benefits for the current year's thresholds.

If you take Ozempic year-round, you will likely hit the coverage gap by fall. Plan ahead by asking your doctor or pharmacist to estimate when you will reach it, so you know when your costs will jump.

Using discount cards and manufacturer programs

Even if you have Part D coverage, a GoodRx coupon or a manufacturer discount card can sometimes cost less than your copay. Ozempic's manufacturer, Novo Nordisk, offers a savings card that can reduce your cost to as low as $99 per month for up to 24 months, depending on your income and insurance status.

Before you use a discount card, tell your pharmacy that you have Medicare Part D. Using a discount card instead of your insurance may affect your out-of-pocket maximum and your progress toward the coverage gap. Some people benefit from this trade-off; others do not. Your pharmacist can run both scenarios and show you which costs less.

The manufacturer's savings card is not the same as a coupon. It is a program you enroll in, and you must meet income limits. Visit Novo Nordisk's website or call 1-844-OZEMPIC to learn whether you may have access to.

Comparing costs across different Part D plans

Your Part D plan's coverage of Ozempic can change every year. A drug that was on Tier 2 last year might move to Tier 3 this year, or a plan might add a prior authorization requirement. During the annual enrollment period (October 15 through December 7), you can switch to a different Part D plan if your current plan's cost for Ozempic has risen.

Use Medicare's Plan Finder tool on Medicare.gov to compare the cost of Ozempic across all Part D plans in your area. Enter your zip code, the drugs you take, and your preferred pharmacies. The tool shows you the monthly copay or coinsurance for each plan, which plans require prior authorization, and the total estimated cost for the year.

If you are considering switching plans, also check whether your current doctor and pharmacy are in the new plan's network. A plan with a lower copay for Ozempic might not include your preferred pharmacy, which could offset the savings.

Frequently Asked Questions

Does Medicare cover Ozempic for weight loss?

Medicare Part D may cover Ozempic for weight loss, but coverage is uncommon and usually requires prior authorization. Your doctor must document that you have a weight-related condition (such as obesity or type 2 diabetes) and that other treatments have not worked. Even when covered, your copay may be higher than for diabetes use. Call your plan to ask whether weight-loss coverage is available under your specific plan.

What if my plan does not cover Ozempic at all?

If your plan's formulary does not include Ozempic, you can ask your doctor to request a formulary exception. Your doctor submits a form explaining why Ozempic is medically necessary for you. The plan usually responds within a few business days. If the exception is denied, you can file an appeal or switch to a different Part D plan during the annual enrollment period.

Can I use a GoodRx coupon instead of my Medicare insurance?

Yes, but check the price first. Run the GoodRx price and your Part D copay through the pharmacy's system before you decide. Using a discount card instead of insurance does not count toward your Part D out-of-pocket maximum or your progress through the coverage gap, which can cost you more money later in the year. Your pharmacist can show you both prices.

Will my Ozempic copay change if I switch pharmacies?

Your copay should be the same at any pharmacy in your Part D plan's network. However, some plans offer lower copays at mail-order pharmacies or preferred retail chains. Check your plan's summary of benefits or call your insurance company to see whether a different pharmacy would lower your cost.

What should I do if my prescription is rejected at the pharmacy?

Ask the pharmacy why it was rejected. Common reasons are prior authorization not yet approved, the drug not on your plan's formulary, or a refill too soon. If prior authorization is the issue, call your doctor's office and ask them to resubmit or expedite the request. If the drug is not covered, ask about a formulary exception or call your plan to discuss switching to a plan that covers it.