Available Mon-Fri, 9am-6pm ET  |  Call 800-970-1964

800.970.1964   |   Contact Us   |   Client Portal

Please Does Medicare Cover Ozempic What to Know

Does Medicare Cover Ozempic? What to Know

Picture of Sylvia Gordon

Sylvia Gordon

Ozempic, a popular medication used to help manage type 2 diabetes, can be an essential part of your healthcare routine. But if you’re a Medicare beneficiary, you may be wondering: does Medicare cover Ozempic? The answer depends on your specific Medicare plan. Generally, Medicare Part D, which covers prescription drugs, may offer coverage for Ozempic if it is prescribed by your doctor for managing type 2 diabetes. However, if you are using Ozempic for weight loss or another non-medical reason, Medicare is unlikely to cover the cost

It’s also important to note that coverage can vary based on the plan you have and where you live. Some Medicare Advantage plans may also offer coverage for Ozempic, especially if they include prescription drug benefits. To find out if your current plan covers Ozempic, you’ll need to check your plan’s formulary or drug list​. If you need assistance navigating these details, consulting a licensed Medicare agent can be a helpful way to make sure you’re getting the coverage you need.

Whether you’re just learning about Medicare or trying to figure out which plan is best for your needs, The Medicare Family is here to help. With over 40 years of experience helping seniors find the right coverage, we can guide you through the process with no cost to you. Schedule a free call with one of our experts today, and let us help you discover the best Medicare plan options in your area!

Understanding Ozempic and Its Uses

Ozempic was first created to help control blood sugar levels. Now, it has become popular for weight loss too. Many people with type 2 diabetes and others looking to lose weight are interested in it. However, it is important to know the difference between its approved uses. The FDA mostly approves Ozempic for managing diabetes. Using Ozempic for weight loss is off-label, which means it is not officially approved for that purpose. This might affect how Medicare covers it.

The difference is key because Medicare treats weight-loss drugs differently than those for specific health issues like type 2 diabetes.

What Is Ozempic?

Ozempic is made by Novo Nordisk. It is an injectable medicine that has semaglutide as its active ingredient. This drug belongs to a class of drugs called GLP-1 receptor agonists. These medicines copy the effects of a natural hormone that helps control blood sugar levels.

Ozempic is mainly used to help adults with type 2 diabetes manage their blood sugar. Many people who take Ozempic also lose weight, which is a common side effect. Studies have shown that those using Ozempic to control diabetes have lost a noticeable amount of weight. This has led to interest in using the drug for weight loss.

It’s important to remember that Ozempic is not approved by the FDA for weight loss alone. Its main purpose is to help manage blood sugar levels in people with type 2 diabetes, combined with diet and exercise.

The Role of Ozempic in Diabetes Management

Ozempic is given to people with type 2 diabetes to help control blood sugar. It does this by boosting insulin release from the pancreas when blood sugar levels go up. Also, Ozempic slows down how fast food leaves the stomach. This can help manage how quickly glucose goes into the blood.

Research shows that Ozempic may also have heart health benefits for those with type 2 diabetes who already have heart disease. Clinical studies suggest that Ozempic can lower the risk of heart attack, stroke, and heart-related death in these cases.

It’s key to note that while Ozempic can help with weight loss, its main aim is to control blood sugar and lessen the chance of problems linked to diabetes, including heart issues.

Medicare Coverage for Prescription Drugs

Medicare beneficiaries often need prescription drug coverage to manage their health. It is important to understand how Medicare covers these medications and what plans are available.

Medicare Part D offers prescription drug coverage, but the benefits can change greatly based on the Part D plan you choose.

Every Part D plan has its own list of covered medications, called a formulary. These plans may also have specific rules like prior authorization or limits on how many medications you can get.

How Medicare Part D Works

Medicare Part D is an optional addition to Original Medicare. It helps cover many prescription drugs. Private insurance companies offer these plans, and each one has its own list of covered medications, called a formulary. Beneficiaries can pick a Part D plan that fits their medicine needs and budget.

Part D coverage usually requires some cost-sharing. This includes monthly premiums, deductibles, copayments, or coinsurance. The costs can change depending on the plan and the tier of the medication.

It is important for Medicare beneficiaries to check and compare different prescription drug plans. This is especially true during the annual enrollment period or when they first become eligible for Medicare. Choosing a plan that includes their important medications and has low out-of-pocket costs is very important.

Eligibility Criteria for Medicare Part D Coverage

Medicare Part D is for people who are signed up for Original Medicare. Original Medicare includes Part A, which is hospital insurance, and Part B, which is medical insurance. You can join a separate Part D plan to help with prescription drug costs or pick a Medicare Advantage plan that has prescription drug coverage.

To use Medicare Part D, you need to meet certain requirements. You must be a U.S. citizen or legally live in the U.S. and be in an area where a Part D plan is available. Usually, people become eligible for Medicare when they turn 65. But, those under 65 with some disabilities or end-stage renal disease can also qualify.

Remember that the sign-up periods for Part D plans usually match Medicare’s yearly enrollment period. This period happens between October 15th and December 7th. If you have certain life changes, like moving or losing other healthcare, you might have special enrollment periods too.

Does Medicare Cover Ozempic?

Medicare Part D coverage for Ozempic varies by plan and the reason it is prescribed. Many Part D plans will cover Ozempic if it is used to improve blood sugar control in people with type 2 diabetes. However, if Ozempic is prescribed only for weight loss, coverage is rare.

This is because Medicare has a history of not covering weight-loss medications under Part D. A federal law prevents Medicare Part D from paying for medications that are mainly prescribed for weight loss or weight gain.

Coverage Conditions for Ozempic under Medicare

Medicare Part D coverage for Ozempic can have some specific rules. First, your Part D plan must list Ozempic in its formulary. This is a list of drugs that are covered. Each Part D plan has its own formulary. So, it’s important to check if Ozempic is on that list.

Second, you will probably need a prescription from a healthcare provider who is enrolled in Medicare for Ozempic to be covered. The prescription needs to show that Ozempic is for its FDA-approved use, like managing type 2 diabetes.

Moreover, some Medicare Part D plans require prior authorization before they cover Ozempic, even for diabetes. This means your doctor must send proof to the plan that Ozempic is necessary for your treatment. There may also be limits on how much Ozempic your plan will cover per prescription or in a certain time period.

Understanding the Coverage Gap

Medicare Part D coverage is changing in 2025 with the elimination of the coverage gap, also known as the ‘donut hole.’ This gap historically affected how much you paid for your drugs after reaching a certain spending threshold. Starting January 1, 2025, instead of entering a coverage gap, you will have a new annual maximum out-of-pocket cost set at $2,000 for prescription drugs. Once you meet your deductible and spend $2,000 out-of-pocket on covered medications, you enter catastrophic coverage, which significantly reduces your costs for the remainder of the year.

Previously, such as in 2024, when you and your plan spent $5,030 on covered drugs, you would reach the coverage gap and pay 25% of the cost for brand-name drugs like Ozempic. Payments made for the deductible, copayments, and drug discounts during the initial coverage phase counted towards reaching this limit.

It’s crucial to understand these changes to Medicare Part D coverage. Knowing about the removal of the coverage gap and the new $2,000 cap will help you plan for your medication expenses more effectively and potentially reduce your out-of-pocket costs, thanks to manufacturer discounts and assistance programs.

Comparable Medications to Ozempic Covered by Medicare

Many medications similar to Ozempic are often covered by Medicare Part D. This gives people with type 2 diabetes other options to manage their blood sugar levels. These drugs are part of the same class, known as GLP-1 receptor agonists.

One option is Rybelsus, which is also made by Novo Nordisk. Like Ozempic, it has semaglutide, but it comes in tablet form. This means it is a non-injectable choice for patients. Another choice is Trulicity (dulaglutide), which is also a GLP-1 receptor agonist. This is an injectable drug given once a week that lowers blood sugar effectively.

Medicare coverage for these alternative GLP-1 receptor agonists is usually similar to Ozempic for managing type 2 diabetes. But, the specific plan details, such as formulary coverage, prior authorization steps, and out-of-pocket costs, can differ based on the Part D plan you choose.

How to Switch Prescriptions within Medicare Guidelines

If your current medication regimen isn’t meeting your needs or is cost-prohibitive under your Medicare Part D plan, you can switch prescriptions while adhering to Medicare guidelines. Here’s a step-by-step approach:

StepDescription
Consult Your DoctorDiscuss your medication concerns with your doctor, including effectiveness, side effects, and cost. They can assess your situation and recommend potential alternatives.
Review Your FormularyCheck your Part D plan’s formulary, a list of covered drugs, to see if the recommended alternative is included. The formulary also outlines any coverage restrictions.
Contact Your PlanIf you’re switching due to cost, ask your plan about less expensive alternatives or if the preferred drug is on a higher formulary tier requiring higher out-of-pocket costs.
Consider Prior AuthorizationSome plans require prior authorization for specific drugs. Your doctor will need to submit documentation to justify the medical need for the new medication.

Remember that switching medications should always involve a conversation and prescription from your doctor to ensure it aligns with your health condition and medical history.

Managing Out-of-Pocket Costs

Managing the costs of medication is very important for people on Medicare, especially for those who need expensive drugs like Ozempic. Luckily, there are a few ways to help lower these costs and make treatment easier to afford.

You can look into discounts from drug makers and their assistance programs. You should also learn about the coverage gaps in Medicare Part D. By taking steps to deal with these possible costs, you can avoid financial stress and keep getting the medications you need.

Tips for Reducing Your Ozempic Expenses

If you have a prescription for Ozempic, you can reduce your costs in a few ways. First, ask your doctor’s office if they have any samples. Many drug companies give free samples to doctors. This could help you get a short supply while you sort out your insurance coverage.

Next, you can ask if you can get a longer dose. For example, if you usually get a monthly supply, your doctor might give you a three-month supply. This could help lower the fees for getting the medicine.

Finally, think about using a different way to take the medicine, like oral medications. Sometimes, oral medications have lower co-pays than injectables.

Programs to Assist with Medication Costs

Exploring programs that help with the costs of prescription drugs is a smart choice for Medicare beneficiaries who find it hard to pay for their medications. These programs work to help people afford the important medicines they need when money is tight.

One helpful program is the Medicare Savings Programs. These are run by Medicaid Services. They assist Medicare beneficiaries with low income and limited resources by paying some Medicare costs. This includes coverage for prescription drugs.

Many drug companies also have patient assistance programs. These programs help people get their medicines for less money or even for free. The rules to join these programs can change, but they often help those without drug coverage or who are facing tough financial times.

Consult a Medicare Specialist

In conclusion, if you’re asking, “Does Medicare cover Ozempic?” the answer depends on a few things. Medicare might help pay for Ozempic if you’re using it to treat type 2 diabetes, but it won’t cover it for weight loss. Also, whether Ozempic is covered will depend on which Medicare plan you have, as different plans might have different rules.

If you’re worried about the cost of Ozempic, there are options to save money, such as savings cards from the manufacturer or patient assistance programs. But, you should definitely check your plan’s details to know exactly what’s covered.

At The Medicare Family, we’re here to help you understand how Medicare works. We can guide you through the different plans so you can find the one that best fits your needs.  Schedule a FREE call today to get free help comparing Medicare plans!

Frequently Asked Questions

Can I get Ozempic covered for conditions other than diabetes?

Ozempic is a drug used for weight loss, but Medicare coverage is mainly for type 2 diabetes. Medicare & Medicaid Services usually do not cover prescription drugs just for weight loss due to federal law. This may change if an Obesity Act is approved or if CMS updates its prescription drug coverage rules.

What if my Medicare plan does not cover Ozempic?

If your Medicare plan does not cover Ozempic, look into how to appeal this decision. Your health insurance company should give you details about the appeal process. You can also reach out to Medicare for help on your rights regarding prescription drug denials.

Can I appeal a Medicare decision if Ozempic is not covered?

Yes, you can appeal if your Medicare plan does not cover Ozempic. First, check your plan’s appeal process document. Make sure to file your appeal within the given time. You usually need to include supporting documents. This may include a letter from your doctor explaining why the prescription drug is necessary, even if you are in a skilled nursing facility.

Sylvia Gordon, aka Medicare Mama®, is an expert on all things Medicare and Social Security. She is the 2nd Generation here at The Medicare Family and has served on the advisory boards of major insurance companies like UnitedHealthcare®, Cigna, and Anthem. In her free time, she can be found taking care of her animals (dogs, goats, peacocks, chickens), and reading a good book. Learn More.
5-stars
5-Star Rated

“This was the best experience I’ve ever had dealing with Medicare information.” – Darrell P.

About Us

For 40 years, our family has been helping seniors understand their Medicare benefits and find the best plan for their unique situation – the best part? Our service is always 100% free to you!

Wouldn’t this be

Easier on video?

Reading about Medicare can be confusing…Thats why we took all the important parts and put them into an easy, free video. 

Get Our FREE Medicare & Social Security Cheat Sheet 

Download this FREE printable cheat sheet to get the information you need in one place. You’ll never worry about forgetting a number, date, or deadline again. UPDATED FOR 2025!

Popular Articles

Beginner's Guide to Medicare

Learn how Medicare works, when and how to sign up, and a breakdown of all the coverage options in this easy guide.

3 Common Medicare Mistakes

There are several severe penalties to make sure you avoid when dealing with Medicare. If you get them, they can stay with you for life.

Medicare Costs for 2025

The costs for Medicare change each year. In this article we break down the costs for Medicare premiums and co-pays.