Does the VA cover Ozempic?

In this article:

• Does the VA cover Ozempic?
• The VA’s national formulary
• Requirements for coverage
• Costs of Ozempic under the VA
• Ways to save

In this article

• Does the VA cover Ozempic?
• The VA’s national formulary
• Requirements for coverage
• Costs of Ozempic under the VA
• Ways to save

Ozempic (semaglutide) is one of the most prominent diabetes medications on the market—one that millions of Americans take for Type 2 diabetes and off-label for obesity. As a GLP-1 drug, it mimics natural hormones to stimulate insulin production, regulate blood sugar levels, and manage appetite. While insurance often covers it for people with diabetes, veterans might wonder if it’s included in their VA health care benefits—it usually is, but that depends on several factors. We’ll cover them all here. 

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Does the VA cover Ozempic?

In some cases, yes. However, patients must meet certain criteria before coverage is issued. The VA will not cover Ozempic when prescribed solely for weight loss, as this is not an FDA-approved use. 

The VA’s national formulary

A formulary is a list that shows how a particular insurance plan covers different drugs, and the VA formulary differs from those that commercial insurance companies use. “Commercial entities will often use their own P&T committees, but regional differences, benefit design strategy, and varying population needs may influence formulary decisions greatly,” says Shannon Fitzgerald, Pharm.D, pharmacist, toxicologist, and contributor at Drugwatch.com. “The VA formulary, in contrast, is managed by the U.S. Department of Veterans Affairs (VA) and is structured on a single, national formulary that is the same across all VA facilities.”

The VA updates this formulary frequently and posts new versions on its website, along with monthly notices about additions and changes. Ozempic is listed on the national formulary, which includes a link to the coverage criteria (see below).

Yet not every drug is on the national formulary. For example, Ozempic’s weight-loss counterpart, Wegovy, isn’t listed. But that doesn’t mean it’s impossible to get coverage. If you need a medication that’s not listed on the formulary, your healthcare provider can submit a non-formulary request.

According to Fitzgerald, this request should include reasons why Wegovy is medically necessary and why other weight loss drugs are not effective. She says the VA pharmacy will review this request within 96 hours, and if it’s denied, the prescriber can make an appeal to the VA care team.

VA requirements for Ozempic coverage

The VA won’t cover Ozempic indiscriminately for everyone. Only for people who meet certain requirements. Typically, patients need prior authorization, which is the process by which they confirm that Ozempic is truly medically necessary. Here are the requirements.

Diagnosis

First and foremost, they need to have a diagnosis of Type 2 diabetes mellitus. According to the Ozempic label, the FDA has only approved it for managing blood glucose and reducing the risk of sustained eGFR decline, end-stage kidney disease, and major cardiovascular events in people with Type 2 diabetes. So the VA needs proof that you have Type 2 diabetes before they’ll cover it.

Medical Necessity

A simple diagnosis, however, isn’t the end of the road. As a prior authorization requirement, patients must have pre-existing atherosclerotic cardiovascular disease and/or chronic kidney disease, and a medical determination that they’re not a good candidate for empagliflozin (brand name: Jardiance). This would be enough evidence that the patient needs Ozempic over cheaper alternatives.

Step Therapy

If the patient doesn’t have cardiovascular or chronic kidney disease, they can go through a process called step therapy—trying certain alternatives first, and moving on to Ozempic if they don’t work. Specifically, patients must try empagliflozin and the maximally tolerated dose of metformin (if they can take it). If neither of these medications achieves the desired results or causes significant side effects, the patient may be eligible for coverage for Ozempic.

What about for weight loss?

The VA won’t cover Ozempic for weight loss, but there’s a chance they might cover Wegovy. A semaglutide drug from the same manufacturer, Novo Nordisk, Wegovy is FDA-approved for weight management, while Ozempic isn’t. Since Wegovy isn’t listed on the national formulary, it will require a non-formulary request, and if the VA approves health benefits, the patient needs to meet the following criteria:

• Participate in a comprehensive lifestyle intervention (CLI) that includes diet, exercise, and behavioral changes.
• Have a body mass index (BMI) of 30 kg/m2 or higher with at least one weight-related health condition, like cardiovascular disease or a metabolic disorder.

Before Wegovy is approved for coverage in a female who can become pregnant, the healthcare provider will confirm a negative pregnancy test and counsel the patient on using effective birth control and potential risks of becoming pregnant during treatment. 

Costs of Ozempic under the VA

The VA’s copays can vary based on the priority group to which you are assigned. People in priority group 1 don’t have copays, while people in groups 2–8 do. Here are the factors that determine your priority group:

• Military service history
• Service-connected disability rating

• Income level
• Medicaid eligibility
• Other benefits

For anyone in groups 2–8, the national formulary’s copays can range from $0 to $33 per prescription, depending on the drug and the amount you’re getting. It divides medications into four different tiers, each with its own rates and coverage.

• Tier 0 (prescription and over-the-counter medicines with no copay): $0
• Tier 1 (preferred generic prescription medications): $5 for 1–30 day supply, $10 for 31–60 day supply, $15 for 61–90 day supply.
• Tier 2 (non-preferred generic prescription medications/some OTC medications): $8 for 1–30 day supply, $16 for 31–60 day supply, $24 for 61–90 day supply.
• Tier 3 (brand-name prescription medications): $11 for 1–30 day supply, $22 for 31–60 day supply, $33 for 61–90 day supply.

The VA puts an annual $700 cap on copays, and once you hit it, you won’t need to pay any other copays for the year, even if you continue getting medications.

Ozempic is a brand-name drug, so you will have a $0 copay if you are in group 1. If you are in groups 2 through 8, your copay will be $11 for a one-month supply, $22 for two months, or $33 for three months. But if you are in groups 2 through 8 and have already paid $700 in copays for the calendar year, you will have a $0 copay. 

Ways to save on Ozempic

Ozempic prices can look intimidating on the surface, especially for people who are paying entirely out of pocket. Ozempic’s manufacturer (Novo Nordisk) also offers patient assistance programs and savings cards that can reduce the drug’s out-of-pocket cost. However, people who have VA benefits aren’t eligible, so you’ll need to look elsewhere for savings. But rest assured that there are effective ways to save on Ozempic, even if you don’t get any coverage from the VA.

For example, SingleCare offers free Ozempic coupons, which can lower the cost by hundreds of dollars. Instead of paying the average $1,400 for a one-month supply, you could pay $825 at CVS with an Ozempic SingleCare discount. It’s free to sign up, and all you have to do is present your SingleCare card at a participating pharmacy.

Beyond that, some people are eligible for Medicaid benefits—even if they’re already receiving VA benefits. State and federal governments jointly fund Medicaid, and the eligibility requirements vary by state.