Does Medicare cover Ozempic?

Over the past year, Ozempic has shown up seemingly everywhere. Its commercials pop up frequently, and celebs have sounded off on its weight loss benefits. Yet the Food and Drug Administration (FDA) hasn’t approved this GLP-1 agonist injection for weight loss. Instead, it’s FDA approved to improve glycemic control in adults with Type 2 diabetes and to reduce the risk of adverse cardiovascular events in adults with Type 2 diabetes and known heart disease.

With such skyrocketing popularity, Americans looking to get their hands on Ozempic might wonder whether they’ll be able to afford it. The truth is that its prices can vary depending on a lot of factors, including insurance coverage. The good news is that many Medicare prescription plans may help pay for Ozempic, although it may depend on the reason for taking it. 

How much does Ozempic cost?

Without insurance, Ozempic costs vary but average about $1,300 per pen (a month’s supply) depending on the dosage, where you live, and which pharmacy you use. One report by the U.S. Public Interest Research Group found that prescription drug prices can vary by up to a few hundred dollars between retailers. A separate study published in 2019 surveyed 68,353 pharmacies across 16,325 ZIP codes and concluded that independent pharmacies and small chains typically charge higher prices than larger chains.  

Typically, brand-name drugs have generic options that cost less, but there’s currently no approved generic semaglutide, which is Ozempic’s active ingredient. Plus, the FDA issued a warning about using unauthorized medications from dubious sources that promote themselves as a generic version of the drug. That said, there are some safe alternatives to Ozempic that may come at lower prices or receive better insurance coverage. 

Does Medicare cover Ozempic?

Older adults who are enrolled in original Medicare (Parts A and B) have the option to add a stand-alone Part D plan to their coverage, which helps pay for certain prescription drugs. People enrolled in Medicare Advantage (Part C) usually have a plan that includes drug coverage. Although each plan has its list of approved prescription medications, Medicare Part D will cover a variety of anti-diabetic drugs, according to Medicare’s official diabetes coverage guide—and that may include Ozempic prescribed for diabetes. 

“That said, even with Medicare coverage, due to the high cost of the drug, many users will end up in the Part D coverage gap (donut hole),” says Scott Maibor, a Medicare advisor and managing director at Senior Benefits Boston. “That will make Ozempic and any other medications they are taking more expensive.” The donut hole is a phase in Part D coverage after the initial coverage phase in which beneficiaries are responsible for paying a greater share of their drug costs until a certain financial limit is reached. 

Unfortunately, a law from 2003 prohibits Medicare Part D from covering weight loss drugs, which means it won’t cover Ozempic prescribed solely for weight loss, an off-label use. This was due to the fact that weight loss medications were considered cosmetic, and obesity wasn’t considered a chronic disease back then, according to Jonathan Kaplan, MD, founder of Pacific Heights Plastic Surgery. “There is federal legislation with bipartisan support for obesity medication coverage, but it’s simply too expensive. Estimates show that if you cover only 10% of Medicare beneficiaries with obesity, it would cost 9.35% of the entire Medicare Part D budget,” Dr. Kaplan says.

If someone wants to treat morbid obesity and also has Type 2 diabetes, though, a Medicare plan may cover Ozempic. 

Factors influencing Medicare coverage of Ozempic for diabetes

In 2021, Medicare spent more than $2.6 billion to cover Ozempic for 458,643 beneficiaries, according to the Centers for Medicare & Medicaid Services. However, each Medicare Part D plan is different, so they may have different requirements for Ozempic coverage. 

For example, certain private health insurers have buckled down on their coverage of Ozempic and other GLP-1 medications, implementing additional policies that may complicate the process. For example, some plans may require prior authorization, which means a doctor must send the prescription to the insurance provider for approval before the patient receives coverage. Other plans may require Medicare beneficiaries to try other medications (or even diets) first before they cover Ozempic. 

Each Medicare prescription drug plan has a formulary, which is a list of all the medications it covers, along with dosages, copays, and alternatives. Formularies usually contain three to five tiers, ranging from generic drugs on tier 1 to specialty brand name drugs on the higher tiers. Each tier has defined copayments and out-of-pocket costs, and most often, the lower the tier, the lower the cost. Many plans put Ozempic somewhere in the middle.

Costs of Ozempic under Medicare

The cost of Ozempic may vary depending on the specific plan since each plan has its own policies regarding cost-sharing—the amount the beneficiary pays out of pocket, including copayments, deductibles, and coinsurance. According to Maibor, the average cost of Ozempic with Medicare coverage is around $2,300 per year, although he affirms that this price may vary. 

For the year 2024, Medicare Part D deductibles will be no more than $545, and copayments can vary. But out-of-pocket maximums are much higher. Out-of-pocket annual expenses for covered medications are capped at $8,000 in 2024. 

Ways to get discounts on Ozempic

Medicare Part D or other health insurance plans might be the most prominent ways to reduce the cost of Ozempic, but it’s not the only one. There are several things you can do to save on Ozempic, but here are five common ones. 

Use a SingleCare savings card

This prescription discount card can immediately reduce the cost of expensive prescription drugs. Part D beneficiaries can’t combine these savings with their Medicare prescription drug coverage, but because each Part D plan has a different formulary, sometimes these coupons could offer more savings. Get your free SingleCare discount card here.

Apply for assistance programs

“I would encourage almost everyone to see if they qualify for any drug cost assistance,” says Maibor. “The federal government has programs with different income tiers, and many states have additional assistance programs with higher income thresholds.” 

Medicare Extra Help is one of the most prominent federal programs. It’s designed to reduce expenses for Medicare beneficiaries who have a limited income and Medicare Part D. To qualify for Extra Help in 2024, beneficiaries must have an annual income below $22,590 for an individual or $30,660 for a married couple, or resources of $17,220 for an individual or $34,360 for a married couple. But Extra Help isn’t the only program available. The Medicare website has a search tool for finding state-specific programs. 

Look for discounts from the manufacturer

Novo Nordisk has a Patient Assistance Program (PAP) that helps uninsured people below 400% of the federal poverty level access Ozempic for free, as long as they meet all the requirements. The company also offers an Ozempic Savings Card for patients who have private insurance, which offers financial assistance of up to $150 per month, $300 for a two-month supply, or $450 for a three-month supply. This offer is only good for two years, and eligibility requirements apply.

Consider a compounded version

Compounding pharmacies mix the active ingredients in a drug themselves. These pharmacies are perfectly legal and may help save money. “Going through a compounding pharmacy is significantly less expensive and offers, by law, a duplicate of the active ingredient semaglutide in Ozempic,” Dr. Kaplan says. 

The law requires compounding pharmacies to make drugs identical to brand-name ones that are on the drug shortage list, but know that the FDA doesn’t always test them. Plus, there are counterfeit versions of semaglutide coming from dubious sources. So, if you go this route, be sure you’re using a reputable, well-vetted source. 

Shop around

This works for most products, but especially for medications since the list price can vary quite a bit between pharmacies and zip codes. Doing a little bit of research or driving an extra few minutes could amount to significant savings.