Is Semaglutide (Ozempic, Wegovy) Covered by Insurance?

Most insurance companies will cover Ozempic only for its FDA-approved indication of treating type 2 diabetes. Some plans require a degree of disease severity or prior experience with other diabetes medications. 

Nearly all Semaglutide prescriptions in the United States were paid with commercial insurance. Fewer individuals used Medicaid and Medicare to pay for Semaglutide prescriptions, and even fewer used cash.

Coverage Variations Across Insurance Plans

• Medicaid covers Ozempic as a treatment for type 2 diabetes in all states. Each state’s online “preferred drug list” (formulary) significantly influences Ozempic coverage. If Ozempic is listed on the state’s Medicaid formulary and doesn’t require prior authorization, it is covered for people with type 2 diabetes. In some states, like Alabama and Texas, patients must provide proof of type 2 diabetes diagnosis, evidence of step therapy with Metformin, and a documented A1C level. 
• If a person with Medicare Part D meets eligibility requirements, they may be covered for several type 2 diabetes medications. The eligibility requirements specify whether prior authorization for covering Ozempic is required. To request coverage, a prior authorization is sent to the insurance company. The cost to the Medicare enrollee depends on the tier at which Ozempic is defined by the plan. 
• Private insurers choose their formulary. If Ozempic is on a specific formulary and a physician certifies that the drug is required, Medicare will pay for it. 

How to Get Insurance Coverage

Patients need to take the following steps to check if their insurance covers Ozempic:

1. Obtain proof of a diagnosis of type 2 diabetes and check if Ozempic is on their formulary.
2. If it’s a preferred drug, check if other clinical criteria and prior authorization are needed; if not, proceed with getting an Ozempic prescription. 
3. If a prior authorization request is required, the health provider must submit the request to the plan first.
4. If Ozempic is not on the state’s formulary, it will not be considered until a predetermined number of preferred medications have failed to produce the desired effects.