Does Medicare cover Ozempic? Yes — but it depends on your Rx

Over 38 million Americans have diabetes, according to the Centers for Disease Control and Prevention (CDC), and more than 90% of these cases are Type 2 diabetes. Managing Type 2 diabetes requires you to monitor your blood sugar levels, carefully plan meals, get regular exercise — and, often, take multiple medications.

Many people are turning to newer medications like Ozempic to manage their Type 2 diabetes more effectively. Others are also turning to it as a weight loss drug.

But does Medicare cover Ozempic? Yes, though it depends on how it's prescribed and how you intend to use it. Here’s a look at how Medicare covers Ozempic as a treatment for diabetes, including what you could end up paying out of pocket.

How Medicare pays for Ozempic

Medicare Part D — Medicare’s prescription drug coverage program — typically covers Ozempic for the drug's FDA-approved use of treating people with Type 2 diabetes. Ozempic is classified as a semaglutide that promotes blood sugar control in the body, lowering blood sugar levels and reducing the risk of heart attack and stroke.

Medicare will not cover Ozempic if it’s prescribed off-label for weight loss.

Most Medicare Part D plans include Ozempic in Tier 3 of their formularies, which has a higher copayment than drugs in Tiers 1 and 2.

If you have Medicare Part D, here’s what you could end up paying for Ozempic:

• Deductibles. The maximum Part D deductible in 2024 is $545, but some plans have lower or no deductibles for preferred drugs.

• Coinsurance. After meeting the deductible, you may pay a percentage of the drug's cost as coinsurance. This percentage varies depending on your plan benefits.

• Coverage gap. Once you and your plan have spent $5,030 (in 2024) on covered drugs, including your deductible, you enter the "donut hole," where you'll pay 25% of the drug's cost.

• Catastrophic coverage. After spending $8,000 out of pocket, you won’t pay any coinsurance or copayment for the rest of the year.

• Medigap. These supplemental policies don't cover prescription drugs, so they won't help with Ozempic costs. You’ll have to pay for Ozempic out of pocket.

Does Medicare Advantage (Part C) pay for Ozempic?

Yes, Medicare Advantage (Part C) plans typically cover Ozempic for Type 2 diabetes if you have a prescription drug plan. Medicare Advantage does not cover Ozempic for weight loss.

Dig deeper: Original Medicare vs. Medicare Advantage: Which should you choose for health coverage?

????How much does Medicare spend on Ozempic?

Medicare Part D spent a total of $4.6 billion on Ozempic in 2022, based on the most recent data we have from the Centers for Medicare & Medicaid Services. This spending covered 780,253 beneficiaries for an average cost of $5,932 per person. The average cost Medicare Part D paid per dose was $468.24, increased from $452.72 in 2021.

Does Medicare cover diabetes testing supplies?

Yes, Medicare Part B generally covers blood glucose testing supplies for diabetics, including:

• Blood sugar monitors

• Lancets and test strips

• Lancet devices

• Glucose control solutions

Medicare typically covers these supplies if you have diabetes. You'll pay 20% of the Medicare-approved amount after the yearly Part B deductible. Confirm that your doctors and medical device suppliers are enrolled and participate in Medicare to head off any unexpected charges or surprise bills.

Does Medicare cover diabetes self-management training?

Medicare Part B covers diabetes self-management training (DSMT) for beneficiaries diagnosed with diabetes. This training includes:

• Nutrition counseling

• Proper blood glucose monitoring

• Exercise recommendations

• Medication management

You'll need a written order from your doctor or qualified non-physician practitioner. Medicare covers up to 10 hours of initial training and up to two hours of follow-up training each year.

How to confirm your Medicare coverage

There are several ways to verify whether your Medicare plan pays for Ozempic:

• Check your Medicare plan documents. Review your annual Evidence of Coverage or Plan Annual Notice of Change and look for Ozempic in the drug formulary or covered medications list.

• Use the Medicare Plan Finder tool. Log in to your account at Medicare.gov and enter Ozempic in the drug search to see if it's covered.

• Contact your Medicare plan directly. Call the customer service number on your Medicare card to ask specifically about Ozempic coverage and any restrictions.

• Consult with your healthcare provider. Discuss your coverage with your doctor or pharmacist. They may have experience with your plan's coverage policies.

• Call 1-800-MEDICARE (1-800-633-4227). This is Medicare’s 24/7 hotline that you can call for personalized assistance. Ask about Ozempic coverage under your specific plan.

• Visit your local State Health Insurance Assistance Program (SHIP). SHIP allows you to get free, unbiased Medicare counseling. Search for your local SHIP for one-on-one assistance.

Remember to have your Medicare number and plan details ready before you call, and keep these four questions handy to ask about Ozempic coverage:

• Is Ozempic covered under my current plan?

• What tier is Ozempic in, and what are my out-of-pocket costs?

• Are there any coverage restrictions or requirements I should know about?

• How does my coverage for Ozempic change throughout the year — for instance, in the coverage gap?

The costs for Ozempic

The list price for Ozempic is $936 for a one-month supply — even though researchers at Yale’s School of Medicine estimate the drug costs less than $1 to manufacture.

• If you have Medicare, the cost for Ozempic depends on your deductible, your coinsurance and your plan’s preferred drug list, but it should be covered if prescribed to treat Type 2 diabetes.

• If you have private or employer-sponsored health insurance, you should be covered if prescribed for Type 2 diabetes.

• If you don’t have insurance, you could pay up to the list price of $936, plus pharmacy fees.

Ways to lower the cost of Ozempic

There are several ways to lower the cost of Ozempic, whether Medicare pays for it or not:

• Manufacturer savings programs and coupons. Novo Nordisk, the manufacturer of Ozempic, offers a savings card it claims can reduce out-of-pocket costs to $25 for a one- to three-month supply. Unfortunately, you can’t use these programs with Medicare due to federal regulations.

• Medicare Extra Help program. You can sign up online for this Medicare program that assists low-income individuals with prescription drug costs. In 2024, single households with an annual income up to $22,590 and resources up to $17,220 — including bank, retirement and investment accounts — may qualify. For married or joint households, those limits increase to $30,660 in annual income and $34,360 in total resources.

• State Pharmaceutical Assistance Programs. At least 48 states offer additional assistance for prescription drug costs through SPAPs. The National Conference of State Legislatures offers a way to search for SPAPs available in your state.

• Patient assistance programs. Novo Nordisk offers a patient assistance program that provides medication at no cost to U.S. citizens or legal residents at or below 400% of the federal poverty level and have Medicare or no insurance.

Dig deeper: 6 simple ways to save money on your prescriptions — without skipping your meds

How to borrow money to pay for Ozempic

If you don't qualify for manufacturer discounts or assistance programs and still need Ozempic, you can look into ways to borrow money to pay for your medical costs. But proceed with caution, and make sure you can comfortably afford any additional monthly payment.

• Personal loans. These are unsecured installment loans you can use for nearly anything, including paying for Ozempic. You can prequalify online in just a few minutes without it affecting your credit score. Learn more about using a personal loan to cover unexpected costs.

• Credit cards. If you have good to excellent credit, you may be able to qualify for a 0% APY credit card offering a no-interest introductory rate for up to 12 months or longer on purchases. While not your best option, Synchrony Bank offers the CareCredit Credit Card, a health and wellness credit card that occasionally offers new customers with good credit a 0% APR for a number of months, if you can qualify. If you prioritize paying your balance before the promotional period ends, you won’t pay any interest.

FAQs: Medicare, drug coverage and your medical options

Learn more about how Medicare works when it comes to paying for prescriptions, including Ozempic and other diabetes-related drugs.

What is the Medicare “donut hole”?

The Medicare donut hole — also called the Medicare coverage gap — is a term used to refer to the temporary limit on what your plan will pay for prescription drugs. After your plan’s payments and the deductibles you’ve paid on covered drugs hit a specified limit, you’ll pay no more than 25% of the cost of brand-name prescriptions, while the full price counts toward your out-of-pocket costs. For generic prescriptions, you’ll pay 25% of the drug’s price but only the amount you pay counts toward out-of-pocket costs — and not the full price.

In 2024, the maximum limit for total drug costs is $5,030. Review your monthly Explanation of Benefits to confirm your coverage, payment and out-of-pocket costs, and call your Medicare plan’s support line if you think there’s a mistake.

Will Medicare pay for Wegovy for weight loss?

Wegovy can be covered by Medicare as of March 2024 if it’s used to treat or prevent heart attacks and strokes in people who are diagnosed as overweight. Similar to Ozempic, Medicare will not cover Wegovy if it’s prescribed solely for weight loss.

What weight loss drugs does Medicare cover?

Medicare doesn’t cover drugs used strictly for weight loss. However, it can cover some drugs — like Ozempic and Wegovy — if they’re used to treat other health conditions, like Type 2 diabetes and cardiovascular disease.

Sources

• About Type 2 Diabetes, U.S. Centers for Disease Control and Prevention. Accessed August 9, 2024.

• Medications Containing Semaglutide Marketed for Type 2 Diabetes or Weight Loss, U.S. Food and Drug Administration. Accessed August 9, 2024.

• What Medicare Part D drug plans cover, U.S. Centers for Medicare and Medicaid Services. Accessed August 9, 2024.

• Costs for Medicare drug coverage, U.S. Centers for Medicare and Medicaid Services. Accessed August 9, 2024.

• Medicare Part D Drug Spending Dashboard, U.S. Centers for Medicare and Medicaid Services. Accessed August 9, 2024.

• How do prices of drugs for weight loss in the U.S. compare to peer nations’ prices? KFF. Accessed August 9, 2024.

• Help with drug costs, U.S. Centers for Medicare and Medicaid Services. Accessed August 9, 2024.

About the writer

Cassidy Horton is a finance writer who specializes in banking, insurance, lending and paying down debt. Her expertise has been featured in NerdWallet, Forbes Advisor, MarketWatch, CNN Underscored, USA Today, Money, The Balance and Consumer Affairs, among other top financial publications. Cassidy first became interested in personal finance after paying off $18,000 in debt in 10 months of graduation with an MBA. Today, she's committed to empowering people to stand up and take charge of their financial futures.