How to get insurance to cover Ozempic for weight loss

In this article:

• When does insurance cover Ozempic for weight loss?
• How to get insurance to cover Ozempic for weight loss
• How much does Ozempic cost without insurance?
• What to do if your health insurance doesn’t cover Ozempic

In this article

• When does insurance cover Ozempic for weight loss?
• How to get insurance to cover Ozempic for weight loss
• How much does Ozempic cost without insurance?
• What to do if your health insurance doesn’t cover Ozempic

Ozempic (semaglutide) is a brand-name injectable prescription medication administered once weekly. It’s in a class of drugs called glucagon-like peptide-1 (GLP-1) receptor agonists, approved by the Food and Drug Administration (FDA) to manage blood sugar levels in adults with Type 2 diabetes when combined with diet and exercise. It’s also approved to reduce the risk of major adverse cardiovascular events in adults with

Type 2 diabetes mellitus and established cardiovascular disease. Weight loss is a common side effect of Ozempic. In fact, the drug often sees shortages due to high demand for off-label prescriptions for weight loss.

Although some healthcare providers prescribe Ozempic off-label for weight loss, insurance often won’t cover Ozempic for these uses unless it’s medically justified and no alternative treatments exist. We’ll explain when insurance covers Ozempic and how to advocate for coverage. We’ll also outline treatment alternatives and ways to lower the cost of Ozempic.

When does insurance cover Ozempic for weight loss?

Ozempic is often covered by insurance, but coverage varies by health insurance plan and the reason for prescribing it. Ozempic isn’t intended to be prescribed solely as a weight loss drug. Managing blood sugar and reducing the risk of major adverse cardiovascular events in people with Type 2 diabetes are the only FDA-approved uses for Ozempic. So, even if your insurance plan covers Ozempic, it may not approve coverage if you want Ozempic solely for weight loss.

“If a patient has Type 2 diabetes and needs weight management, Ozempic could be covered because it’s within the scope of its primary FDA approval,” said Danielle Kelvas, MD, a primary care physician with The HCG Institute, a telehealth weight loss company.

Although Ozempic is FDA-approved solely for diabetes management, healthcare providers might prescribe it for non-diabetic weight loss in medically justified cases—like when alternative treatments have been ineffective for weight-related medical issues. 

RELATED: How to get Ozempic prescribed for weight loss

Healthcare professionals weigh in on possible non-diabetic exceptions for Ozempic coverage:

• Weight-related medical conditions: “Insurance might cover semaglutide for weight management in patients with a body mass index (BMI) of 30 or greater, or at least 27 with a weight-related health condition such as hypertension, Type 2 diabetes, or dyslipidemia,” Kelvas said.
• Obesity treatment: “Most insurance plans primarily cover GLP-1s [like Ozempic] for diabetes management. Coverage for obesity treatment, however, is less common and varies among plans. Typically, each health plan sets its own policies regarding coverage for anti-obesity medications. Due to the high cost of these medications, many insurance plans impose strict qualification criteria, which can vary depending on the specific plan,” said Eldad Einav, MD, board-certified cardiologist and obesity medicine specialist at Drugwatch.

Medicaid and Medicare Ozempic coverage

If you’re insured, coverage will ultimately depend on your insurance company’s policies. Medicaid sometimes covers Ozempic for diabetes, but coverage isn’t guaranteed and varies by state. Check your state’s preferred drug list online or call the number on your insurance card to learn more. 

Medicare Ozempic coverage varies depending on the plan you’re enrolled in, since they typically “restrict coverage to cardiac patients with a history of cardiovascular diseases, such as heart attacks and strokes,” Einav said.

How to get insurance to cover Ozempic for weight loss

It’s difficult to get Ozempic prescribed for weight loss that is unrelated to Type 2 diabetes. That said, some healthcare providers may prescribe Ozempic off-label for weight loss related to other medical conditions, according to Kelvas. “Insurance companies often have strict rules about covering off-label drug use, so it might be challenging to get coverage for this reason unless it is medically justified, and there’s no alternative,” Kelvas said. 

Prior authorization might be required for Ozempic to demonstrate its medical necessity, depending on your insurance provider. Prior authorization means your healthcare provider must get permission from your insurance company before prescribing a medication. 

If your insurance provider requires prior authorization for Ozempic, make sure your healthcare provider has all your relevant medical history to request authorization. This might include medical records for past treatments, lifestyle changes, and comorbid conditions related to your medical condition. Relevant comorbid conditions might include prediabetes, high cholesterol, high blood pressure, or obstructive sleep apnea, according to Einav.

Step therapy is another possible requirement for Ozempic coverage, depending on your insurance provider. Step therapy is a type of prior authorization where your insurance provider requires you to try cheaper or safer medications first. If the first medication(s) don’t work, the insurance provider is more likely to approve the more expensive or complex medication. Make sure to keep evidence of any failed previous treatments in case your insurance requires it.

To determine Ozempic coverage, your insurance provider will compare your medical records with their coverage criteria, which can vary significantly, according to Einav: “Some plans might cover anti-obesity medications for individuals with a BMI over 30, or at least 27 with additional comorbid conditions. Additionally, certain commercial insurance plans require a documented period of three to six months of enrollment in a lifestyle program before qualifying for the medication.”

How much does Ozempic cost without insurance?

Due to its high demand, Ozempic often experiences shortages and carries a hefty price tag. Ozempic’s pricing fluctuates, but without insurance, the typical cash price of a single Ozempic pen is about $1,295. Healthcare providers typically prescribe a weekly injection, and there are four doses per Ozempic pen.

Ozempic pricing will depend on your prescription dosage and pharmacy. Comparison shopping at different pharmacies may be able to save you money on Ozempic. 

What to do if your health insurance doesn’t cover Ozempic

If you get an initial “no” from your insurance company for Ozempic coverage, that doesn’t mean all hope is lost. You may still be able to get Ozempic coverage if your healthcare provider seeks clarification about the initial insurance denial. Or your healthcare provider may file an appeal with your insurer to explain why Ozempic coverage is medically necessary.

If your insurance still doesn’t cover Ozempic, your healthcare provider may advise you to consider alternative treatments or medications. 

Request clarification

Before escalating to an appeal, your healthcare provider may be able to ask your insurance provider for clarification first. This is a possible first route, especially if the claim denial seems unjust. 

“Your doctor can request a clarification from the health plan and may engage in a peer-to-peer discussion to explore the reasons behind the denial, Einav said. “If additional documentation is needed, it can be submitted at this stage.”

File an appeal

If your insurance denies Ozempic coverage, your healthcare provider can file an appeal to advocate for its medical necessity. Appeal processes vary by insurance provider, according to Jessica DeGore, a registered dietitian nutritionist. “It really comes down to the provider supplying the appropriate documentation to verify Ozempic is specifically required for their patient,” DeGore said.

Consider treatment alternatives

If Ozempic is too pricey for your budget, consult your healthcare provider about possible Ozempic alternatives. You might also check your insurance plan’s formulary to find alternative Type 2 diabetes drugs or weight-loss medication options that your plan covers.

• Wegovy is an oral weight-loss medication with the same active ingredient as Ozempic (semaglutide). “Technically, Ozempic is not FDA-approved for weight loss, but its sister medication, Wegovy, is the FDA-approved weight loss version of Ozempic,” DeGore said. “It is FDA-approved for chronic weight management in people with a BMI of 30 or higher or 27 or higher if they have a weight-related health condition.”
• Rybelsus is an oral medication alternative that Kelvas recommends. It treats Type 2 diabetes with Ozempic’s same active ingredient, semaglutide.
• Trulicity (dulaglutide) and Victoza (liraglutide) are injectable prescription medications that treat Type 2 diabetes. According to DeGore, coverage might be better for these two medications because they’re in the same GLP-1 agonist drug class as Ozempic, work through the same mechanism, yet tend to be less costly.
• Mounjaro (tirzepatide) is also an injectable prescription medication that treats Type 2 diabetes. It’s classified as a dual glucose-dependent insulinotropic polypeptide (GIP) and GLP-1 receptor agonist. 

Explore other ways to get affordable Ozempic

With or without insurance coverage, there are ways to save on Ozempic:

• Use a free Ozempic coupon from SingleCare. Your SingleCare prescription discount card provides access to coupons you can use at pharmacies around the country. With an Ozempic coupon from SingleCare, you could pay $786 for each Ozempic pen instead of $1,295 (saving you about $500 per pen). SingleCare provides access to drug prices from multiple pharmacies near you so you can choose the most affordable option. Anyone, with or without insurance, can use SingleCare coupons, but they can’t be used together. Compare your copay cost using insurance with the SingleCare cost so you can choose the most affordable option in the long term.  
• Use the manufacturer’s patient assistance program. Uninsured patients can apply for Novo Nordisk’s Patient Assistance Program (PAP) for free Ozempic access. Patients must meet certain income requirements and cannot be enrolled in private insurance, Medicare, or any other state, federal, or government health insurance programs.
• Apply for the Ozempic copay card. Patients with private or commercial health insurance can apply for the Ozempic Savings Card from Novo Nordisk. If eligible, you could pay $25 a month on a one-, two-, or three-month prescription for up to two years.

RELATED: How do I get Ozempic for $25 a month?

• Compare pharmacy prices. If you’re willing to trade convenience for savings, you can compare local pharmacy costs. When paying without insurance, a chain pharmacy may be your best bet. According to a study published in 2019, independent pharmacies and small chains often charge more than big box pharmacies when you’re paying cash prices (without insurance). You can also look for Ozempic using online pharmacies, where pricing varies.