Medicare Part D covers Ozempic, but only if your specific plan includes it and you meet the plan's requirements

Whether your Medicare Part D plan covers Ozempic (semaglutide) depends on which plan you chose and what that plan's formulary lists. A formulary is the official list of drugs your plan will pay for. Some Part D plans cover Ozempic with no restrictions. Others cover it only if your doctor first tries a different, cheaper diabetes drug and documents that it did not work for you — a requirement called prior authorization. Still others do not cover it at all.

The only way to know what your plan covers is to check your plan's formulary or call the plan directly. Your plan sends you an updated formulary every year, usually in September or October. You can also find it on Medicare.gov by searching your plan name, or call your plan's customer service number — it is on your insurance card.

Key Takeaways

  • Your Part D plan's formulary lists which drugs it covers; some plans cover Ozempic with no restrictions, others require prior authorization, and some do not cover it at all.
  • Prior authorization means your doctor must document that you tried another diabetes drug first and it did not work before the plan will pay for Ozempic.
  • You can find your plan's formulary on Medicare.gov, in the materials your plan mailed you, or by calling your plan's customer service number.
  • If your plan does not cover Ozempic or the cost is too high, you may be able to switch to a different Part D plan during the annual enrollment period in October and November.
  • Ozempic is approved by Medicare for type 2 diabetes only, not for weight loss alone, so your doctor's diagnosis must be type 2 diabetes for any plan to consider covering it.

How to check your plan's formulary

Start by going to Medicare.gov and clicking "Find Care Providers & Suppliers" or "Find Prescription Drug Plans." Enter your zip code and the name of your current plan. The search will show you a link to your plan's formulary — usually a PDF file you can read or read online. Search the document for "semaglutide" or "Ozempic" to see how your plan classifies it.

If you do not have internet access or prefer to speak with someone, call your Part D plan's customer service number. It is printed on your insurance card. Have your member ID ready. Ask the representative directly: "Is Ozempic covered under my plan?" and "If it is covered, do I need prior authorization?" Write down the answer and the name of the person who gave it to you.

What prior authorization means for Ozempic

If your plan covers Ozempic only with prior authorization, your doctor must submit a request to the plan before you can fill the prescription. The plan will ask your doctor to show that you have type 2 diabetes and that you have already tried at least one other diabetes medication — usually a drug like metformin or a GLP-1 receptor agonist in a different class — and that it either did not work well enough or caused side effects you could not tolerate.

Prior authorization can add one to three business days to the process of getting your prescription filled. Your doctor's office usually handles the paperwork, but it is worth calling your plan ahead of time to ask what documentation they need. Some plans post their prior authorization requirements on their website; others only explain them when the request comes in.

What to do if your plan does not cover Ozempic

If your current Part D plan does not cover Ozempic at all, you have two main options. The first is to ask your doctor whether another diabetes medication on your plan's formulary might work for you instead. Your doctor can tell you which drugs your plan covers and whether any of them are appropriate for your situation.

The second option is to switch to a different Part D plan during the annual enrollment period, which runs from October 15 through December 7 each year. During this window, you can drop your current plan and join a new one that does cover Ozempic. You can also switch if your current plan's cost for Ozempic is very high — for example, if the copay or coinsurance is more than you can afford. Use the Medicare plan comparison tool on Medicare.gov to see which plans in your area cover Ozempic and what the out-of-pocket cost would be.

Understanding your out-of-pocket costs

Even if your plan covers Ozempic, you will still pay something out of pocket. Part D plans typically charge a copay (a flat dollar amount per prescription) or coinsurance (a percentage of the drug's cost). Ozempic is an expensive drug — the full price is often several hundred dollars per month — so your share can be substantial.

Your plan's formulary should list what tier Ozempic is on. Tier 1 drugs are usually the cheapest; Tier 4 or 5 drugs are the most expensive. The higher the tier, the more you pay. Some plans also have a specialty tier for very expensive drugs, which may require a higher copay or coinsurance. Ask your plan what your specific copay or coinsurance will be before you fill the prescription.

If the cost is too high, ask your doctor about patient information programs run by the drug manufacturer. Novo Nordisk, which makes Ozempic, offers programs that may reduce your cost if you meet income requirements. Your doctor's office or the manufacturer's website can tell you how the process works.

Medicare coverage for Ozempic used for weight loss only

Medicare Part D does not cover Ozempic when it is prescribed for weight loss alone. The drug is approved by Medicare only for treating type 2 diabetes. If you have type 2 diabetes and your doctor prescribes Ozempic, your plan may cover it. If you do not have a diabetes diagnosis and want Ozempic for weight management, Medicare will not pay for it, and you would need to pay the full cost yourself.

This is an important distinction because Ozempic has become popular for weight loss in people without diabetes. If you are interested in the drug for that reason, talk to your doctor about whether a diabetes diagnosis applies to you and whether other weight-loss treatments might be covered by your plan instead.

What to ask your doctor and your plan

Before you fill a prescription for Ozempic, ask your doctor these questions: "Do I have type 2 diabetes?" (Medicare will only cover Ozempic for this diagnosis.) "Is Ozempic the right first choice for me, or should I try another drug first?" and "If my plan requires prior authorization, will you handle the paperwork?"

Ask your Part D plan: "Is Ozempic on my formulary?" "If it is, what tier is it on and what will my copay or coinsurance be?" "Do I need prior authorization?" and "If my plan does not cover it, can you tell me which diabetes drugs you do cover?"

When to contact Medicare directly

If your Part D plan tells you Ozempic is not covered and you believe it should be, or if you disagree with a prior authorization denial, you have the right to appeal. Contact Medicare at 1-800-MEDICARE (1-800-633-4227) to ask about the appeal process. You can also file a complaint with Medicare if you think your plan is not following its own rules.

If you are having trouble affording Ozempic even with your plan's coverage, ask your plan whether you may have access to for the Part D Extra Help program, which reduces copays and coinsurance for people with limited income. You can explore through Social Security or at Medicare.gov.

Frequently Asked Questions

Does Medicare Part B cover Ozempic instead of Part D?

No. Part B covers injectable drugs that are administered in a doctor's office or hospital. Ozempic is a self-injected drug you use at home, so it falls under Part D, which covers prescription drugs you pick up at a pharmacy. If your doctor were to inject Ozempic for you in the office, Part B might cover that visit, but the drug itself would still be a Part D cost.

Can I use GoodRx or a discount card if my Part D plan does not cover Ozempic?

Yes. If your plan does not cover Ozempic or the copay is very high, you can use a discount card like GoodRx or ask your pharmacy whether they offer a lower price without insurance. Compare the discount price to your plan's copay and use whichever is cheaper. Tell your pharmacist which payment method you want to use before they process the prescription.

What happens to my Ozempic coverage if I switch Part D plans?

Coverage depends on your new plan's formulary. A new plan might cover Ozempic with no restrictions, require prior authorization, or not cover it at all. Before you switch plans, use the Medicare plan comparison tool to check whether your new plan covers Ozempic and what your out-of-pocket cost would be. You can switch plans only during the annual enrollment period or if you have a may have access to life event.

If my doctor prescribes Ozempic off-label for something other than type 2 diabetes, will Medicare cover it?

Medicare Part D covers drugs only for the uses approved by the FDA. Ozempic is approved for type 2 diabetes, so that is the only use Medicare will pay for. If your doctor prescribes it for another condition, your plan will likely deny the claim, and you would pay out of pocket.

How long does prior authorization take?

Most plans respond to prior authorization requests within one to three business days. Some respond faster. Ask your doctor's office to submit the request as soon as possible and to follow up with the plan if you do not hear back within three days. If the plan denies the request, your doctor can appeal or discuss alternative medications with you.