Does Aetna cover Ozempic?

In this article:

• Does Aetna cover Ozempic?
• Does Aetna Medicare cover Ozempic?
• Does Aetna require prior authorization for Ozempic?
• What does Ozempic cost with Aetna?
• What if Aetna won't cover Ozempic?
• Expert takeaway
• FAQs

In this article

• Does Aetna cover Ozempic?
• Does Aetna Medicare cover Ozempic?
• Does Aetna require prior authorization for Ozempic?
• What does Ozempic cost with Aetna?
• What if Aetna won't cover Ozempic?
• Expert takeaway
• FAQs

Ozempic (semaglutide) is a GLP-1 receptor agonist used to treat Type 2 diabetes, but with its list price exceeding $1,300 per pen, insurance coverage matters. Whether Aetna covers Ozempic depends on the indication and the specific plan, which makes the answer more nuanced. 

Does Aetna cover Ozempic?

Yes, Aetna typically covers Ozempic for indications approved by the FDA, including the treatment of Type 2 diabetes, reducing the risk of chronic kidney disease and cardiovascular deaths, and reducing the risk of major adverse cardiovascular events in adults. However, Aetna doesn’t cover Ozempic for off-label use for weight loss. 

Ozempic for Type 2 diabetes

Aetna usually requires prior authorization before covering Ozempic for Type 2 diabetes. You must meet certain criteria before Aetna approves your Ozempic prescription. 

The criteria vary slightly depending on whether you’re taking Ozempic for the first time or renewing your prescription.

Aetna covers new Ozempic prescriptions for Type 2 diabetes if: 

• You haven’t been taking a stable maintenance dose of any glucose-dependent insulinotropic polypeptide (GIP) or GLP-1 medications for at least three months.
• You meet at least one diagnostic criterion for Type 2 diabetes (such as an A1C blood sugar test result of 6.5% or higher, or a fasting plasma glucose of 126 mg/dL or higher). 
• You can’t tolerate metformin, or it hasn’t worked for you in the past.

Aetna covers continued Ozempic use for Type 2 diabetes if:

• You’ve been taking a stable maintenance dose of Ozempic for at least three months. 
• You have met at least one diagnostic criterion for Type 2 diabetes in the past. 
• Your A1C has decreased since starting Ozempic. 

If you don’t meet the metformin or A1C reduction criteria, Aetna may still approve your Ozempic prescription if you have Type 2 diabetes and another FDA-approved indication, such as cardiovascular disease. 

Ozempic for prediabetes

Aetna doesn’t cover Ozempic for prediabetes. People with prediabetes tend to show higher-than-normal-range numbers on an A1C, fasting glucose, or oral glucose tolerance tests. However, those numbers aren’t high enough for a Type 2 diabetes diagnosis, which Aetna requires for Ozempic coverage. 

Ozempic for weight loss

Aetna doesn’t cover Ozempic as it isn’t FDA-approved for weight loss. Puzzlingly, semaglutide (the active ingredient in Ozempic) has been FDA approved for weight loss under the brand name Wegovy. Wegovy offers a slightly stronger dose of semaglutide compared to Ozempic. 

Some Aetna plans cover Wegovy, such as the Aetna Standard Plan and the Aetna Advanced Control Plan. Check your insurance plan’s rules for weight-loss medications and see which medical conditions must be diagnosed for the medication to be covered. If you’re seeking coverage for a weight loss medication, other options are Wegovy or Foundayo, which are FDA-approved specifically for weight management. Ask your provider for information.

Does Aetna Medicare cover Ozempic?

Yes, Aetna Medicare plans typically cover Ozempic for FDA-approved indications, such as Type 2 diabetes. Typically, Aetna Medicare plans impose quantity limits on Ozempic, meaning you can only get a one-month supply with each refill. 

Historically, federal law has prevented Medicare plans from covering weight loss medications. The Medicare GLP-1 Bridge program temporarily changes that from July 1, 2026, to December 31, 2027. You can get a one-month supply of Wegovy, a semaglutide drug approved specifically for weight loss, for a $50 copay through that program if you have a Medicare Part D prescription drug plan from Aetna or any other insurance provider. 

Does Aetna require prior authorization for Ozempic?

Yes, most Aetna plans, including Medicare, require prior authorization for Ozempic. Your healthcare provider will need information from you to answer Aetna’s specific prior authorization questions. Then, they submit the prior authorization paperwork proving your diagnosis. 

If your prior authorization request is denied, your healthcare provider can help you appeal it. They’ll write a letter to Aetna explaining why Ozempic is medically necessary for you and why other medications won’t provide the same results. 

“In practice, patients who get denied can’t get approval if the primary intention for using Ozempic is for obesity without diabetes, even if they have significant metabolic risk factors,” says Kyle Hoedebecke, MD, a board-certified physician based in Spring, Texas. Hoedebecke also says to review your plan’s formulary every year if you’re denied coverage, as policies can change between enrollment cycles

What does Ozempic cost with Aetna?

The cost of Ozempic with Aetna varies by plan. Once you meet your plan’s deductible, you’ll pay coinsurance (a percentage of the cash price) or a copay (a fixed-rate amount). Coinsurance and copays depend on how Ozempic is labeled in the plan’s drug formulary. 

For example, some Medicare plans assign Ozempic to Tier 5, which is the most expensive cost-sharing tier. Others assign it to a lower tier. Usually, medications on Tier 3 or higher require coinsurance, while Tier 1 and Tier 2 drugs require a copay. 

Non-Medicare plans may describe Ozempic as either a preferred brand (PB) or a non-preferred brand (NPB). You’ll get better coverage if Ozempic is labeled PB on your specific plan’s drug list. If Ozempic is labeled NPB, it may only be covered if your healthcare provider says it’s medically necessary. 

You’ll pay out-of-pocket for Ozempic until you meet your plan’s deductible, then switch to a copay or coinsurance. The cash price of Ozempic is about $1,395 per 1, 3 mL prefilled 2 mg/3 mL multidose pen (0.25 mg or 0.5 mg/dose). If you don’t have coverage, you can use a SingleCare coupon to pay as little as $792 per pen at pharmacies near you. Enter your ZIP code to compare prices. 

What if Aetna doesn’t cover Ozempic?

If Aetna doesn’t cover Ozempic, ask your healthcare provider to submit an exception request on your behalf. They’ll write to Aetna to explain why Ozempic is the best medication for your diagnosis.

You can also ask your healthcare provider about Ozempic alternatives. For example, if you want to take Ozempic for weight loss, you might have better luck getting coverage for medications FDA approved for that indication, such as Wegovy or Foundayo (orforglipron).

If you have a commercial (non-government) Aetna plan that doesn’t cover Ozempic, you may also be eligible for Novo Nordisk’s savings card. You can also use a SingleCare coupon to compare Ozempic prices at pharmacies near you. Enter your ZIP code to get started.

Expert takeaway

Leslie Greenberg, MD, Associate Professor of Family and Community Medicine at the University of Nevada, Reno Family Medicine Residency Program, and member of the SingleCare Medical Review Board, states, “Getting insurance to cover a weight-loss medication can be like fitting the last piece into a puzzle. Every requirement has to match. It can take a lot of time and paperwork, and the insurance company may still decide not to pay for it.”  

“It is best to know your insurance company’s specific rules for coverage. Bring paperwork to your office visit that your insurance requires to help streamline the process. And, be patient.”

Frequently asked questions

How much is Ozempic without insurance?

Ozempic costs an average of $1,395 for 1, 3 mL prefilled 2 mg/3 mL multidose pen (0.25 mg or 0.5 mg/dose) without insurance, but you could pay $792 per 3 mL pen with an Ozempic coupon from SingleCare.

Will Aetna approve Ozempic for weight loss?

Aetna is unlikely to approve Ozempic for weight loss because this is an off-label indication. However, Aetna may cover Wegovy, which contains the same active ingredient as Ozempic and is FDA-approved for weight loss. 

What BMI do you need for insurance to cover Ozempic?

Body mass index (BMI) isn’t part of Aetna’s coverage criteria for Ozempic because it’s not approved for weight loss. If you’re interested in Wegovy, Aetna requires a BMI of 35 kg/m² or higher in adult patients. Pediatric patients aged 12 to 17 must have a weight in the 95th percentile for their age and sex.