Does Medicaid cover Ozempic?

Ozempic (semaglutide) is an injectable medication 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 it’s been gaining a lot of momentum. Because it often leads to weight loss, it’s become an in-demand drug for patients with type 2 diabetes and patients looking to lose weight, even though it’s not currently FDA approved for weight loss. 

The price of Ozempic, which is part of a class of drugs called GLP-1 agonists, is high compared to many other drugs, costing roughly $1,000 for a one-month supply. But how much each individual person will end up paying for Ozempic varies. Factors influencing its price include insurance coverage, access to discounts and coupons, and the pharmacy filling the prescription.

People prescribed Ozempic may be surprised to find that Medicaid does, in some cases, cover the drug. But it’s not a guarantee; Medicaid only covers Ozempic if certain criteria are met, such as if you’re taking it for diabetes instead of solely for weight loss. Here’s what you need to know about whether your Medicaid coverage will pay for Ozempic.

How much does Ozempic cost?

According to Novo Nordisk, the manufacturer of Ozempic, the list price of the drug is $935.77 regardless of dosage. The list price is how much a drug costs without any insurance coverage, before any other discounts or rebates are applied. The list price can vary greatly by pharmacy. Currently, you can expect to pay between $1,200 and $1,400 without using insurance or discounts. One thing that doesn’t affect Ozempic’s list price is your reason for taking it. “Whether you’re taking Ozempic for diabetes or weight loss, the [list] price remains the same,” says Christie Kunde, Pharm.D., of Informed Rx.

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 savings card (more on that later). 

With insurance, including Medicaid, your cost will be based on factors like your prescription coverage, your copay, and your deductible. 

Does Medicaid cover Ozempic?

According to Brian Staiger, Pharm.D., of HelloPharmacist, Medicaid coverage varies on a state-by-state basis. He says Ozempic is generally covered by Medicaid as a treatment for Type 2 diabetes in all states, but the question is 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.

“Every state publishes its ‘preferred drug list’ online,” Dr. Staiger says, “which is likely the easiest way for individuals to find out about drug coverage under their plan.”

“You can find that preferred list of drugs one of two ways,” Dr. Staiger adds. One is by typing your state name and “preferred drug list” into the search box of your internet browser, and the other is by calling the phone number on your insurance card. 

The preferred drug list, or prescription drug formulary, for your state’s 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.

“If Ozempic is listed on your state’s Medicaid formulary and doesn’t require any prior authorization, you may be able to obtain it through Medicaid regardless of your diagnosis,” Dr. Kunde says. But if Ozempic isn’t on the formulary or requires prior authorization, it would most likely only be potentially covered for people with Type 2 diabetes. 

Factors influencing Medicaid coverage for Ozempic

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 off-label use of Ozempic since it’s only approved by the FDA for Type 2 diabetes. 

Even if you’re 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’s on their preferred drug list, but most still require some clinical criteria, which he says typically include:

• A diagnosis code of Type 2 diabetes
• Evidence of step therapy with the drug metformin (Step therapy involves first trying to use a lower-cost drug to treat a condition.)
• In some states, a documented A1C amount—a lab value indicating your blood sugar levels that’s often used in the diagnostic process for diabetes

So what happens if Ozempic isn’t on your state’s 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. 

“If 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,” 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. 

For example, in the state of Virginia—where Ozempic is a non-preferred drug—Dr. Staiger says Medicaid coverage for Ozempic won’t be considered unless you have an A1C of at least 6.5% along with a trial and failure of two preferred GLP-1 drugs, such as Victoza and Trulicity. But in Ohio, he adds, you need a trial and failure of three preferred drugs for at least 120 days before nonpreferred drugs like Ozempic will be considered.

The eligibility requirements may be different in your state, so it’s important to check your specific insurance plan.

Ozempic versus Wegovy

“It’s worth noting that some state Medicaid programs do cover weight loss drugs—just not Ozempic,” Dr. Kunde says. 

“In states where weight loss medications are covered, individuals seeking to use it for weight loss should consider requesting Wegovy instead of Ozempic,” she advises. “Both 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.”

In other words, if you’re hoping to use a semaglutide injection for weight loss, live in a state where Wegovy is covered, and receive Medicaid coverage, ask your doctor whether Wegovy may be an option instead.

How to get Ozempic with Medicaid

It’s easy to feel overwhelmed by the process of seeking health insurance coverage for Ozempic, so we’ve broken it down into steps for you based on our experts’ advice:

1. Obtain proof of a diagnosis of type 2 diabetes.
2. See if Ozempic is preferred or nonpreferred on your state’s Medicaid plan.
   • If it’s 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 is required, your provider will need to submit that request to your plan first.
   • If Ozempic is not on your state’s 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. 
3. Meet any nonpreferred drug and prior authorization criteria required by your state’s plan. Once you have performed the required steps, you can proceed with getting an Ozempic prescription from your healthcare provider.

Again, all of these steps are highly state-dependent. Check with your Medicaid plan or ask your provider for assistance if you’re not sure how to proceed.

Costs of Ozempic with Medicaid

What you can expect to pay for Ozempic with Medicaid coverage varies by state. While all 50 states currently offer prescription drug coverage to Medicaid members, costs are different based on whether or not a drug is on your state’s formulary, among other factors. Typically, Medicaid prescription medication copays cost less than $8 as long as they meet your state’s requirements for coverage. In some cases, there may be no copay at all. 

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, drug copays may be waived if the patient is under a certain age or if the medicine falls into a specific category (like smoking cessation or family planning drugs). 

We can’t tell you how much Ozempic will cost on your state’s 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.

*Listed copays are just examples and may vary by plan.

Ways to get discounts on Ozempic without Medicaid

If your insurance won’t 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 SingleCare prescription discount card, for example, you can use it to check the cost of Ozempic at local pharmacies and fill your prescription at the one with the best discount. 

You can also check the Novo Nordisk website for savings cards, coupons, and rebates to see if you qualify for any Ozempic savings or apply to the Novo Nordisk Patient Assistance Program.