Ozempic (Semaglutide) Medicare Coverage

Ozempic is a drug used to lower blood sugar and A1C in people with type 2 diabetes. Ozempic is one of several types of drugs that can help lower the risk of major cardiovascular events such as strokes, heart attacks and death.¹ 

Medicare beneficiaries with type 2 diabetes may want to find out if Ozempic is covered by Medicare. In this review, we outline Medicare drug coverage options and how Ozempic may be covered by a Medicare drug plan.

Medicare drug plan availability and coverage may vary, so it’s important to speak with a licensed insurance agent or compare plans online to find out which Medicare plans near you may cover Ozempic.

Is Ozempic paid for by Medicare?

While Original Medicare (Medicare Part A and Part B) does not typically cover prescription drugs like Ozempic, Medicare Advantage (Medicare Part C) and Medicare Part D plans may cover Ozempic or similar medications that help beneficiaries manage diabetes.

According to GoodRx, 93% of Medicare prescription drug plans cover Ozempic.¹

What kinds of Medicare plans cover prescription drugs like Ozempic?

Medicare Advantage plans are sold by private insurance companies and serve as an alternative way to get all your Medicare Part A and Part B coverage. In addition to those benefits, Medicare Advantage plans typically offer coverage for some extra things not covered by Original Medicare. 

Medicare Advantage plans that offer prescription drug coverage are called Medicare Advantage Prescription Drug Plans (MA-PD). Most Medicare Advantage plans (88 percent) offer prescription drug coverage in 2023. 99% of beneficiaries have access to an MA-PD plan with no monthly premium, though you typically must continue to pay your monthly Part B premium.²

Medicare prescription drugs plans each have their own formulary, or drug list, that details what prescription drugs are covered by the plan and how they are covered.

Drug coverage may vary based on plan availability. You may be able to find Medicare Advantage plan options in your area that cover Ozempic, but coverage isn't guaranteed. Be sure to request a free plan comparison and enter your drugs to find out if plans where you live cover Ozempic.

You can compare standalone Part D prescription drug plans available where you live and enroll in a Medicare prescription drug plan online if you're eligible when you visit MyRxPlans.com.

There are certain Medicare enrollment periods each year that may be your only time to change or add Medicare drug coverage, unless you qualify for a Special Enrollment Period. A licensed agent can help you confirm your eligibility.

How much does Ozempic cost with Medicare?

The costs you may pay for Medicare drug coverage can vary per plan, but your coverage costs for drugs like Ozempic are typically subject to a four-phase system. 

Deductible phase

Before any coverage of a drug like Ozempic begins, you will first have to meet your plan’s annual deductible.

Deductible amounts vary by plan, and some plans have $0 deductibles. In 2023, no plan is allowed to have a drug deductible of more than $505. 70% of standalone Part D plans charge the standard $505 deductible in 2023.²

Initial coverage coinsurance or copayment phase

Once your deductible has been met, you begin the cost-sharing portion of your coverage. During this phase, you will make a copayment each time you fill a prescription. Copayment amounts are based on tiers, with Tier 1 drugs generally having the lowest copayments and Tier 5 drugs usually having the highest. 

In 2023, the average Medicare Part D plan charges a $1 copay for Tier 1 preferred generic drugs, while the average plan coinsurance for Tier 5 specialty drugs is 25%.² 

Donut hole phase

If you and your drug plan combine to spend at least $4,660 on covered medications in 2023, you will exit the initial coverage phase and enter the “donut hole” phase coverage gap.

While in the coverage gap, you pay no more than 25% of the cost of your medications until you and your plan have combined to spend $7,400 on covered medications for the year in 2023.

Catastrophic coverage phase

If you and your plan combine to spend $7,400 on covered medications in 2023, you exit the donut hole phase and enter the catastrophic coverage phase. Once here, your plan will only charge a small coinsurance or copay for covered drugs for the remainder of the year. 

Does Medicare have any coverage restrictions on Ozempic?  

Some Medicare drug plans may have restrictions on the amount of a drug that may be filled at one time.

Plans may also have a network of participating pharmacies where the plan must be used or preferred pharmacies where plan members may save on out-of-pocket costs for covered drugs. 

What is the cost of Ozempic without insurance?

The retail cost of Ozempic without insurance in 2023 is around $1,000 for a 2mg pen of 2mg/1.5ml.¹

Does Ozempic have any side effects?

Ozempic manufacturer Novo Nordisk lists the following possible side effects when taking the drug:

• Nausea
• Diarrhea
• Stomach pain
• Vomiting
• Constipation 

How else does Medicare cover diabetes treatment?

In addition to various prescription drugs and insulin, Medicare Advantage prescription drug plans and Part D plans can also cover diabetes supplies such as:

• Blood sugar testing strips
• Glucose testing monitors
• Therapeutic shoes
• Lancet devices and more

99% of Medicare Advantage plans offer some type of fitness benefit, such as memberships to gyms and wellness programs like SilverSneakers in 2023.³

How do I enroll in a Medicare drug plan?

If you’re new to Medicare, you may still be in your Initial Enrollment Period. This begins three months before you turn 65 years old and ends three months after your birthday month, for a total of seven months. You may enroll in a Medicare Advantage or Medicare Part D plan during this time.

If you are not new to Medicare, your best opportunity to enroll in a plan that may cover Ozempic is most likely during the fall Medicare Open Enrollment Period, which lasts from October 15 to December 7 each year. 

Contact a licensed insurance agent to shop for and compare plans available in your area, including what drugs they may cover and how much they cost. 

Review our Guide to Managing Diabetes to learn how to better manage your diabetes.