{"id":627236,"date":"2024-03-07T11:58:57","date_gmt":"2024-03-07T16:58:57","guid":{"rendered":"https:\/\/www.singlecare.com\/blog\/?p=627236"},"modified":"2025-03-07T15:28:16","modified_gmt":"2025-03-07T20:28:16","slug":"does-medicaid-cover-ozempic","status":"publish","type":"post","link":"https:\/\/www.singlecare.com\/blog\/does-medicaid-cover-ozempic\/","title":{"rendered":"Does Medicaid cover Ozempic?"},"content":{"rendered":"<p><a href=\"https:\/\/www.singlecare.com\/prescription\/ozempic\"><span style=\"font-weight: 400;\">Ozempic<\/span><\/a><span style=\"font-weight: 400;\"> (semaglutide) is an injectable medication that was initially approved by the Food and Drug Administration (FDA) to treat Type 2 diabetes. It stimulates insulin production in the pancreas, lowering overall blood sugar and leading to better health outcomes. <\/span><a href=\"https:\/\/www.singlecare.com\/prescription\/ozempic\/what-is\"><span style=\"font-weight: 400;\">Ozempic<\/span><\/a><span style=\"font-weight: 400;\"> is still relatively new to the market, but the <\/span><a href=\"https:\/\/www.singlecare.com\/drug-classes\/glp-1-agonists\"><span style=\"font-weight: 400;\">GLP-1 agonist<\/span><\/a><span style=\"font-weight: 400;\"> has gained a lot of attention. Because it often leads to weight loss, it\u2019s become an in-demand drug for <\/span><a href=\"https:\/\/www.singlecare.com\/blog\/best-diabetes-drug-for-weight-loss\/\"><span style=\"font-weight: 400;\">patients with Type 2 diabetes <\/span><i><span style=\"font-weight: 400;\">and <\/span><\/i><span style=\"font-weight: 400;\">patients looking to lose weight<\/span><\/a><span style=\"font-weight: 400;\">, even though it\u2019s not currently FDA approved for weight loss.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Because the drug is so popular, and there\u2019s no generic alternative, it can be expensive without insurance. If you\u2019re wondering whether <\/span><a href=\"https:\/\/www.singlecare.com\/blog\/what-is-medicaid\/\"><span style=\"font-weight: 400;\">Medicaid<\/span><\/a><span style=\"font-weight: 400;\"> covers Ozempic, the answer is: It depends. Here\u2019s what you need to know about whether your Medicaid coverage will pay for Ozempic.<\/span><\/p>\n<h2 id=\"how-much-does-ozempic-cost\"><span style=\"font-weight: 400;\">How much does Ozempic cost?<\/span><\/h2>\n<p><span style=\"font-weight: 400;\">How much someone ends up paying for Ozempic depends on several factors, including insurance coverage, access to discounts and coupons, and the pharmacy filling the prescription. Currently, the average retail price of Ozempic without insurance is $1,349, but that price varies by pharmacy and location. One thing that doesn\u2019t affect Ozempic\u2019s cost is your reason for taking it. \u201cWhether you&#8217;re taking Ozempic for diabetes or weight loss, the price remains the same,\u201d says <\/span><a href=\"https:\/\/informedrxllc.com\/about-us\"><span style=\"font-weight: 400;\">Christie Kunde, Pharm.D.<\/span><\/a><span style=\"font-weight: 400;\">, of Informed Rx.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">You could save money on Ozempic by shopping between pharmacies to find a lower price or using manufacturer coupons, a patient assistance program, or a prescription discount card (more on that later).\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">With insurance, including Medicaid, your cost will be based on factors like your prescription plan\u2019s formulary, your copay, and your deductible.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">\t\t<div class=\"singlecare-dynamic-newsletter-wrapper sin-newsletter-wrapper\">\n\t\t\t<span class=\"heading\">Get our diabetes newsletter<\/span>\n\t\t\t<form class=\"form-wrapper\" data-newsletter-form=\"1\" data-subsource=\"Diabetes Newsletter\">\n\t\t\t\t<div class=\"input-wrapper\">\n\t\t\t\t\t<label for=\"dynamic-email\">Email<\/label>\n\t\t\t\t\t<input type=\"email\" id=\"dynamic-email\" class=\"email\" required>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"input-wrapper\">\n\t\t\t\t\t<input class=\"submit-form-btn\" type=\"submit\" value=\"Click to sign up\">\n\t\t\t\t<\/div>\n\t\t\t<\/form>\n\t\t\t<p class=\"success-message\" aria-live=\"polite\"><\/p>\n\t\t<\/div>\n\t<\/span><\/p>\n<h2 id=\"does-medicaid-cover-ozempic\"><span style=\"font-weight: 400;\">Does Medicaid cover Ozempic?<\/span><\/h2>\n<p><span style=\"font-weight: 400;\">According to <\/span><a href=\"https:\/\/hellopharmacist.com\/authors\/brian-staiger\"><span style=\"font-weight: 400;\">Brian Staiger, Pharm.D.<\/span><\/a><span style=\"font-weight: 400;\">, of HelloPharmacist, Medicaid coverage varies on a state-by-state basis. He says Medicaid generally covers Ozempic as a treatment for Type 2 diabetes in all states, but the question is more about how easy it is to receive that coverage, including whether or not Ozempic is listed as a preferred drug in your state and whether it requires any prior authorization or includes other restrictions.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">\u201cEvery state publishes its &#8216;preferred drug list&#8217; online,\u201d Dr. Staiger says, \u201cwhich is likely the easiest way for individuals to find out about drug coverage under their plan.\u201d<\/span><\/p>\n<p><span style=\"font-weight: 400;\">\u201cYou can find that preferred list of drugs one of two ways,\u201d Dr. Staiger adds. One is by typing your state name and \u201cpreferred drug list\u201d into the search box of your internet browser, and the other is by calling the phone number on your insurance card.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">The preferred drug list, or <\/span><a href=\"https:\/\/www.singlecare.com\/blog\/what-is-a-formulary\/\"><span style=\"font-weight: 400;\">prescription drug formulary<\/span><\/a><span style=\"font-weight: 400;\">, for your state\u2019s Medicaid coverage plays a big role in determining whether or not you can receive coverage for Ozempic. In addition, many states mandate that people with Medicaid join a managed Medicaid plan through an insurance carrier. Drug formularies may vary somewhat between these plans.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">\u201cIf Ozempic is listed on your state&#8217;s Medicaid formulary and doesn\u2019t require any prior authorization, you may be able to obtain it through Medicaid regardless of your diagnosis,\u201d Dr. Kunde says. But if Ozempic requires prior authorization, it would most likely only be potentially covered for <\/span><a href=\"https:\/\/www.singlecare.com\/blog\/type-1-vs-type-2-diabetes\/\"><span style=\"font-weight: 400;\">people with Type 2 diabetes<\/span><\/a><span style=\"font-weight: 400;\">.\u00a0<\/span><\/p>\n<h2 id=\"factors-influencing-medicaid-coverage-for-ozempic\"><span style=\"font-weight: 400;\">Factors influencing Medicaid coverage for Ozempic<\/span><\/h2>\n<p><span style=\"font-weight: 400;\">Currently, the majority of states have Medicaid criteria that disallow coverage of Ozempic as a weight loss drug. This is because weight loss is an <\/span><a href=\"https:\/\/www.singlecare.com\/blog\/off-label-prescription-drugs\/\"><span style=\"font-weight: 400;\">off-label use<\/span><\/a><span style=\"font-weight: 400;\"> of Ozempic since it\u2019s approved by the FDA for Type 2 diabetes and to reduce the risk of major cardiovascular events in adults with diabetes and known heart disease. In January 2025, it was also approved to reduce the risk of worsening kidney disease and cardiovascular death in adults with <\/span><a href=\"https:\/\/www.novonordisk-us.com\/media\/news-archive\/news-details.html?id=915253\"><span style=\"font-weight: 400;\">Type 2 diabetes and chronic kidney disease<\/span><\/a><span style=\"font-weight: 400;\">.\u00a0<\/span><\/p>\n<p><b>RELATED: <\/b><a href=\"https:\/\/www.singlecare.com\/blog\/can-i-take-ozempic-if-im-not-diabetic\/\"><b>Can I take Ozempic if I\u2019m not diabetic?<\/b><\/a><\/p>\n<p><span style=\"font-weight: 400;\">Even if you\u2019re prescribed Ozempic for the treatment of Type 2 diabetes, there may still be some hoops to jump through in getting Medicaid coverage. According to Dr. Staiger, some states will cover Ozempic with no clinical requirements if it\u2019s on their preferred drug list, but most still require some clinical criteria, which he says typically include:<\/span><\/p>\n<ul>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">A diagnosis code of Type 2 diabetes<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Evidence of step therapy with the drug metformin (Step therapy involves first trying to <\/span><a href=\"https:\/\/www.cms.gov\/newsroom\/fact-sheets\/medicare-advantage-prior-authorization-and-step-therapy-part-b-drugs\"><span style=\"font-weight: 400;\">use a lower-cost drug<\/span><\/a><span style=\"font-weight: 400;\"> to treat a condition.)<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">In some states, a documented A1C amount\u2014a lab value indicating your blood sugar levels, which is often <\/span><a href=\"https:\/\/www.cdc.gov\/diabetes\/managing\/managing-blood-sugar\/a1c.html#:~:text=The%20A1C%20test%E2%80%94also%20known,care%20team%20manage%20your%20diabetes.\"><span style=\"font-weight: 400;\">used in the diagnostic process for diabetes<\/span><\/a><\/li>\n<\/ul>\n<p><span style=\"font-weight: 400;\">So what happens if Ozempic isn\u2019t on your state\u2019s formulary? You may still be able to receive coverage for the drug as a diabetes treatment, but you need to meet some additional criteria first.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">\u201cIf Ozempic is nonpreferred on your Medicaid plan, you will most likely need to try and fail a certain number of preferred drugs for a certain number of days before you can receive coverage,\u201d Dr. Staiger says, adding that the number of drugs will vary between individual states but is typically two or three. Your plan may also specify which drugs can be tried.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">For example, in the state of Virginia\u2014where Ozempic is a non-preferred drug\u2014Dr. Staiger says Medicaid coverage for Ozempic won\u2019t be considered unless you have an <\/span><a href=\"https:\/\/www.singlecare.com\/blog\/normal-a1c-levels\/\"><span style=\"font-weight: 400;\">A1C<\/span><\/a><span style=\"font-weight: 400;\"> of at least 6.5% and have first tried two preferred GLP-1 drugs, such as <\/span><a href=\"https:\/\/www.singlecare.com\/prescription\/victoza\"><span style=\"font-weight: 400;\">Victoza<\/span><\/a><span style=\"font-weight: 400;\"> and <\/span><a href=\"https:\/\/www.singlecare.com\/prescription\/trulicity\"><span style=\"font-weight: 400;\">Trulicity<\/span><\/a><span style=\"font-weight: 400;\">. But in Ohio, he adds, you need to have tried and failed three preferred drugs for at least 120 days before nonpreferred drugs like Ozempic will be considered.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">The eligibility requirements may be different in your state, so it\u2019s important to check your specific insurance plan.<\/span><\/p>\n<h3 id=\"ozempic-versus-wegovy\"><span style=\"font-weight: 400;\">Ozempic versus Wegovy<\/span><\/h3>\n<p><span style=\"font-weight: 400;\">\u201cIt&#8217;s worth noting that some state Medicaid programs do cover weight loss drugs\u2014just not Ozempic,\u201d Dr. Kunde says.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">\u201cIn states where weight loss medications are covered, individuals seeking to use it for weight loss should consider requesting <\/span><a href=\"https:\/\/www.singlecare.com\/prescription\/wegovy\"><span style=\"font-weight: 400;\">Wegovy<\/span><\/a><span style=\"font-weight: 400;\"> (semaglutide) instead of Ozempic,\u201d she advises. \u201cBoth medications contain the same active ingredient, semaglutide, [but while] Ozempic is FDA approved for Type 2 diabetes, Wegovy is FDA-approved specifically for weight loss.\u201d<\/span><\/p>\n<p><span style=\"font-weight: 400;\">In other words, if you\u2019re hoping to use a semaglutide injection for weight loss, live in a state where Wegovy is covered, and receive Medicaid coverage, ask your healthcare provider whether Wegovy may be an option instead.<\/span><\/p>\n<p><b>RELATED: <\/b><a href=\"https:\/\/www.singlecare.com\/blog\/wegovy-vs-ozempic\/\"><b>Wegovy vs. Ozempic<\/b><\/a><\/p>\n<h2 id=\"how-to-get-ozempic-with-medicaid\"><span style=\"font-weight: 400;\">How to get Ozempic with Medicaid<\/span><\/h2>\n<p><span style=\"font-weight: 400;\">It\u2019s easy to feel overwhelmed by the process of seeking health insurance coverage for Ozempic, so we\u2019ve broken it down into steps for you based on our experts\u2019 advice.<\/span><\/p>\n<ul>\n<li aria-level=\"1\"><b>Obtain proof of a diagnosis of Type 2 diabetes.<\/b><\/li>\n<li aria-level=\"1\"><b>See if Ozempic is preferred or nonpreferred on your state\u2019s Medicaid plan.<\/b><\/li>\n<\/ul>\n<ol>\n<li style=\"list-style-type: none;\">\n<ol>\n<li style=\"list-style-type: none;\">\n<ol>\n<li style=\"font-weight: 400;\" aria-level=\"2\"><span style=\"font-weight: 400;\">If it\u2019s a preferred drug, check if there are other clinical criteria needed, such as step therapy with metformin or an A1C test result. Also, check if prior authorization is needed; if not, you can proceed with getting an Ozempic prescription from your provider. If a prior authorization request <\/span><i><span style=\"font-weight: 400;\">is <\/span><\/i><span style=\"font-weight: 400;\">required, your provider will need to submit that request to your plan first.<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"2\"><span style=\"font-weight: 400;\">If Ozempic is not on your state\u2019s formulary, you may need to try and fail at least two other preferred diabetes drugs first. Check with your plan to see how many drugs are required and if they need to be specific drugs.\u00a0<\/span><\/li>\n<\/ol>\n<\/li>\n<\/ol>\n<\/li>\n<\/ol>\n<ul>\n<li aria-level=\"1\"><b>Meet any nonpreferred drug and prior authorization criteria required by your state\u2019s plan. <\/b><span style=\"font-weight: 400;\">Once you have performed the required steps, you can proceed with getting an Ozempic prescription from your healthcare provider.<\/span><\/li>\n<\/ul>\n<p>Again, all of these steps are highly state-dependent. Check with your Medicaid plan or ask your provider for assistance if you\u2019re not sure how to proceed.<b><\/b><\/p>\n<h2 id=\"costs-of-ozempic-with-medicaid\"><span style=\"font-weight: 400;\">Cost of Ozempic with Medicaid<\/span><\/h2>\n<p><span style=\"font-weight: 400;\">What you can expect to pay for Ozempic with Medicaid coverage varies by state. While <\/span><a href=\"https:\/\/www.medicaid.gov\/medicaid\/prescription-drugs\/index.html\"><span style=\"font-weight: 400;\">all 50 states currently offer prescription drug coverage to Medicaid members<\/span><\/a><span style=\"font-weight: 400;\">, costs are different based on whether or not a drug is on your state\u2019s formulary, among other factors. Typically, <\/span><a href=\"https:\/\/www.kff.org\/medicaid\/issue-brief\/management-and-delivery-of-the-medicaid-pharmacy-benefit\/\"><span style=\"font-weight: 400;\">Medicaid prescription medication copays cost less than $8<\/span><\/a><span style=\"font-weight: 400;\"> as long as they meet your state\u2019s requirements for coverage. In some cases, there may be no copay at all.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Factors that can influence your Medicaid drug copay amount include preferred drugs versus nonpreferred, brand name versus generic drugs, the cost of Medicaid reimbursement for a drug, and whether the drug requires prior authorization or not. Sometimes, <\/span><a href=\"https:\/\/www.kff.org\/other\/state-indicator\/state-medicaid-pharmacy-copay-requirements\/?currentTimeframe=0&amp;sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D\"><span style=\"font-weight: 400;\">drug copays may be waived<\/span><\/a><span style=\"font-weight: 400;\"> if the patient is under a certain age or if the medicine falls into a specific category (like smoking cessation or family planning drugs).\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\">We can\u2019t tell you how much Ozempic will cost on your state\u2019s Medicaid plan, but we can give you a few examples of how drug pricing varies based on these factors. In the chart below, we compare Medicaid prescription drug copays in New York, Indiana, and Vermont.<\/span><\/p>\n<table class=\" singlecare-table\">\n<thead>\n<tr>\n<th>\n<h3 id=\"sample-medicaid-prescription-drug-copays\"><span class=\"title\">Sample Medicaid prescription drug copays*\u00a0<\/span><\/h3>\n<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr class=\"header-row\">\n<td><b>State<\/b><\/td>\n<td><b>Copay Benefit<\/b><\/td>\n<\/tr>\n<tr>\n<td><a href=\"https:\/\/member.emedny.org\/pharmacy\/benefits\" target=\"_blank\" rel=\"noopener\"><span style=\"font-weight: 400;\">New York<\/span><\/a><span style=\"font-weight: 400;\"> (NYRx)<\/span><\/td>\n<td>\n<ul>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">$3 for non-preferred brand-name drugs<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">$1 for generic drugs, preferred brand-name drugs, and some other drugs<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td><a href=\"https:\/\/www.in.gov\/dcs\/files\/Medicaid-Pharmacy-Benefits.pdf\" target=\"_blank\" rel=\"noopener\"><span style=\"font-weight: 400;\">Indiana<\/span><\/a><\/td>\n<td>\n<ul>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Between $3 and $10, depending on generic vs. brand name and the specific Medicaid plan you\u2019re on<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td><a href=\"https:\/\/dvha.vermont.gov\/members\/medicaid\" target=\"_blank\" rel=\"noopener\"><span style=\"font-weight: 400;\">Vermont<\/span><\/a><\/td>\n<td>\n<ul>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">$1 for prescriptions with Medicaid reimbursement costing less than $30<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">$2 for prescriptions with Medicaid reimbursement costing $30 or more but less than $50<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">$3 for prescriptions with Medicaid reimbursement costing more than $50<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span style=\"font-weight: 400;\">*Listed copays are just examples and may vary by plan.<\/span><\/p>\n<h2 id=\"ways-to-get-discounts-on-ozempic-without-medicaid\"><span style=\"font-weight: 400;\">Ways to get discounts on Ozempic without Medicaid<\/span><\/h2>\n<p><span style=\"font-weight: 400;\">If your insurance won\u2019t cover the cost of Ozempic, there are still ways to avoid paying full price. Dr. Kunde says there are many online coupons that can be accessed by signing up for a savings program. If you have a <\/span><a href=\"https:\/\/www.singlecare.com\/prescription-discount-card\"><span style=\"font-weight: 400;\">SingleCare prescription discount card<\/span><\/a><span style=\"font-weight: 400;\">, for example, you can compare the cost of Ozempic at local pharmacies and fill your prescription at the one with the best coupon. With a <\/span><a href=\"https:\/\/www.singlecare.com\/prescription\/ozempic\"><span style=\"font-weight: 400;\">SingleCare coupon for Ozempic<\/span><\/a><span style=\"font-weight: 400;\">, you could pay $811 per month instead of $1,349. <\/span><\/p>\n<p><span style=\"font-weight: 400;\">Novo Nordisk has a <\/span><a href=\"https:\/\/www.novocare.com\/diabetes\/help-with-costs\/pap.html\"><span style=\"font-weight: 400;\">patient assistance program<\/span><\/a><span style=\"font-weight: 400;\"> for Medicare beneficiaries and people without insurance who are at or below 400% of the federal poverty level, but it isn\u2019t available to Medicaid beneficiaries. Additionally, the <\/span><a href=\"https:\/\/www.ozempic.com\/savings-and-resources\/save-on-ozempic.html\"><span style=\"font-weight: 400;\">Ozempic savings card<\/span><\/a><span style=\"font-weight: 400;\"> is only available to people with private or commercial insurance. <\/span><\/p>\n<p><span style=\"font-weight: 400;\">If you\u2019re concerned about paying out of pocket for Ozempic, speak with your healthcare provider. They may be able to recommend other ways to save on your Type 2 diabetes medication or prescribe an <\/span><a href=\"https:\/\/www.singlecare.com\/blog\/ozempic-alternatives\/\"><span style=\"font-weight: 400;\">Ozempic alternative<\/span><\/a><span style=\"font-weight: 400;\">. <\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Ozempic (semaglutide) is an injectable medication that was initially approved by the Food and Drug Administration (FDA) to treat Type 2 diabetes. It stimulates insulin production in the pancreas, lowering overall blood sugar and leading to better health outcomes. Ozempic is still relatively new to the market, but the GLP-1 agonist has gained a lot [&hellip;]<\/p>\n","protected":false},"author":149,"featured_media":627237,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[4589],"tags":[10298,21067,16,9825],"coauthors":[8860],"class_list":["post-627236","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-drug-info","tag-diabetes","tag-glp-1-drugs","tag-medicaid","tag-weight-loss","wpautop"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.4 (Yoast SEO v27.4) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Does Medicaid cover Ozempic?<\/title>\n<meta name=\"description\" content=\"Medicaid may cover Ozempic for diabetes but not weight loss alone. 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