Updated: 2/01/226
Medicare may cover Ozempic, but only in specific situations. Original Medicare and Medicare Part D plans generally cover Ozempic when it is prescribed for an FDA-approved medical use, such as type 2 diabetes. Coverage depends on the plan’s prescription drug formulary and whether the drug is considered medically necessary.
Medicare does not cover Ozempic when it is prescribed solely for weight loss.
Federal law excludes medications used for weight loss from Medicare Part D coverage, even if the drug causes weight loss as a side effect.
This exclusion is established under Section 1860D-2(e)(2)(A) of the Social Security Act, which governs Medicare Part D coverage exclusions.
Because prescription drug coverage varies by plan, beneficiaries should review their plan’s formulary and coverage rules to confirm whether Ozempic is covered for their specific medical condition.
Key Takeaway
- Medicare may cover Ozempic when it is prescribed for an FDA-approved medical condition, such as type 2 diabetes.
- Medicare does not cover Ozempic when it is prescribed solely for weight loss, even though weight loss is a common side effect.
- Coverage depends on the beneficiary’s Medicare Part D or Medicare Advantage plan formulary and medical necessity requirements.
Why Medicare Coverage of Ozempic Is Limited
Medicare coverage of Ozempic is limited because of federal law governing prescription drug benefits, not because of the drug itself.
Under the Medicare Part D statute, medications prescribed solely for weight loss are excluded from coverage. This exclusion applies even if a drug is widely prescribed or produces weight loss as a side effect.
Ozempic is approved by the U.S. Food and Drug Administration (FDA) to treat type 2 diabetes, not as a weight-loss medication. When Ozempic is prescribed for its FDA-approved medical use, Medicare Part D or Medicare Advantage prescription drug plans may cover it, depending on the plan’s formulary and medical necessity rules.
However, if Ozempic is prescribed only for weight loss, Medicare does not cover it under current law, regardless of the prescribing provider or the beneficiary’s health status.
In short, Medicare coverage is determined by:
- The drug’s approved medical use
- The reason it is prescribed
- And whether that use is allowed under federal Medicare law
How Medicare Part D Covers Ozempic
Medicare prescription drug coverage for Ozempic is provided through Medicare Part D or a Medicare Advantage plan that includes prescription drug coverage, as explained on Medicare.gov’s prescription drug coverage overview.
If Ozempic is prescribed for an FDA-approved medical use, such as type 2 diabetes, a Part D plan may cover the medication, but coverage is not guaranteed. Each plan maintains its own drug formulary, which determines whether Ozempic is covered and under what conditions.
When Ozempic is included on a plan’s formulary, coverage may still involve:
- Tier placement, which affects monthly copayments or coinsurance
- Prior authorization, requiring the prescriber to document medical necessity
- Step therapy, meaning other diabetes medications must be tried first
Even when covered, beneficiaries are responsible for applicable out-of-pocket costs, which can vary widely by plan and by phase of Part D coverage.
Because formularies and coverage rules can change each year, beneficiaries should review their current plan’s formulary documents or contact their plan directly to confirm whether Ozempic is covered for their specific medical condition.
Does Medicare Advantage Cover Ozempic?
Medicare Advantage plans (also called Part C) provide prescription drug coverage through an included Part D benefit. As a result, coverage rules for Ozempic under Medicare Advantage generally follow the same standards as standalone Part D plans.
A Medicare Advantage plan may cover Ozempic when it is prescribed for an FDA-approved medical use, such as type 2 diabetes, and when the drug appears on the plan’s formulary. Coverage is subject to plan-specific rules, including medical necessity requirements.
Medicare Advantage plans do not cover Ozempic when it is prescribed solely for weight loss, because they must follow the same federal coverage exclusions that apply to Part D.
Coverage details, cost-sharing, and utilization controls can vary significantly between Medicare Advantage plans, even within the same service area.
Medicare Advantage vs. Original Medicare + Part D
| Feature | Medicare Advantage (Part C) | Original Medicare + Part D |
| Prescription drug coverage | Included in most plans | Provided through a separate Part D plan |
| Ozempic coverage for diabetes | May be covered if on formulary | May be covered if on formulary |
| Ozempic coverage for weight loss | Not covered | Not covered |
| Prior authorization | Common | Common |
| Step therapy | Possible | Possible |
| Cost-sharing structure | Plan-specific copays or coinsurance | Depends on Part D plan design |
| Annual formulary changes | Yes | Yes |
Beneficiaries enrolled in Medicare Advantage should review their plan’s drug formulary, prior authorization rules, and cost-sharing details each year to determine whether Ozempic is covered for their specific medical condition.
How Much Does Ozempic Cost With Medicare?
The cost of Ozempic under Medicare depends on the beneficiary’s prescription drug plan, the drug’s formulary tier, and the phase of Part D coverage.
When Ozempic is covered for an approved medical use, beneficiaries typically pay a share of the cost through copayments or coinsurance rather than the full retail price. Monthly out-of-pocket costs can vary widely based on the plan’s design.
Several factors influence what a beneficiary pays:
- Formulary tier placement, which determines cost-sharing levels
- Whether the plan requires prior authorization or step therapy
- The phase of Medicare Part D coverage (deductible, initial coverage, or catastrophic coverage)
- Pharmacy type (preferred vs. non-preferred)
Even with coverage, Ozempic can remain expensive, particularly if it is placed on a higher formulary tier or subject to coinsurance rather than a flat copay.
Because prescription drug costs and formularies can change each year, beneficiaries should review their plan’s Annual Notice of Change and current formulary documents to estimate costs for the upcoming year.
Important Cost Note
Manufacturer coupons and savings cards for Ozempic generally cannot be used by Medicare beneficiaries. Federal rules prohibit coupon use in combination with Medicare prescription drug coverage.
Does Medicare Cover Ozempic for Weight Loss?
Medicare does not cover Ozempic when it is prescribed solely for weight loss, even if a beneficiary meets medical criteria for obesity.
Under federal law, Medicare prescription drug coverage excludes medications used for weight loss. This exclusion applies regardless of how effective the medication may be or how commonly it is prescribed.
Although weight loss is a well-known effect of Ozempic, Medicare coverage is based on the medical purpose of the prescription, not on treatment outcomes. If Ozempic is prescribed for an FDA-approved condition such as type 2 diabetes, Medicare Part D or Medicare Advantage prescription drug plans may cover it, even if weight loss also occurs during treatment.
In those cases, plans typically require documentation showing medical necessity for the approved use.
Medications approved specifically for weight loss are generally subject to the same Medicare exclusion unless federal law changes.
In short, Medicare coverage depends on why Ozempic is prescribed, not on weight loss results.
What Are Your Options If Medicare Doesn’t Cover Ozempic?
If Medicare does not cover Ozempic for your situation, there are several steps you can take to understand why and explore alternatives.
Understand Why Coverage Was Denied
Start by reviewing the plan’s denial notice to confirm the reason coverage was denied. Denials commonly occur because the prescription is not for an FDA-approved indication, required medical documentation was not submitted, or the drug is excluded under Medicare coverage rules.
If the denial is based on Ozempic being prescribed solely for weight loss, appeals are generally unsuccessful. This exclusion is set by federal Medicare law rather than by individual plan discretion.
When Ozempic is prescribed for an approved medical condition, such as type 2 diabetes, a healthcare provider may submit additional documentation or request an exception through the plan’s prior authorization or appeals process. These requests typically focus on medical necessity and alignment with FDA-approved use.
If coverage remains unavailable, beneficiaries may want to discuss alternative treatment options with their healthcare provider. Other medications for diabetes management may be covered under Medicare and could be appropriate depending on individual medical needs.
In most cases, next steps depend on whether the denial is administrative or required by federal Medicare law.
Frequently Asked Questions
Does Original Medicare (Part A and Part B) cover Ozempic?
Original Medicare does not cover most outpatient prescription drugs, including Ozempic. Coverage for Ozempic is available only through Medicare Part D or a Medicare Advantage plan that includes prescription drug coverage.
Can Medicare Part B ever cover Ozempic?
Medicare Part B primarily covers drugs administered in clinical settings, and self-administered prescription drugs like Ozempic are generally covered under Part D instead, according to Medicare coverage rules outlined by the Centers for Medicare & Medicaid Services (CMS).
Is prior authorization required for Ozempic?
Many Medicare Part D and Medicare Advantage plans require prior authorization for Ozempic. This process usually requires the prescriber to document that the drug is being used for an FDA-approved medical condition and is medically necessary.
Does Medicare cover Ozempic for prediabetes?
Coverage for Ozempic prescribed for prediabetes is uncommon. Because prediabetes is not an FDA-approved indication for Ozempic, many plans deny coverage unless additional qualifying medical conditions are documented.
Can I switch Medicare plans to get better coverage for Ozempic?
You may be able to change plans during Medicare Open Enrollment if another plan in your area offers more favorable coverage. However, no Medicare plan can cover Ozempic when it is prescribed solely for weight loss.
Do Medicare coverage rules change from year to year?
Yes. Medicare Part D and Medicare Advantage formularies, cost-sharing, and coverage rules can change annually. Beneficiaries should review their plan’s Annual Notice of Change each year to understand how coverage may be affected.
Are there any exceptions for weight-loss coverage under Medicare?
Under current federal law, Medicare does not cover prescription drugs used solely for weight loss. Exceptions are rare and generally require a change in federal statute rather than plan-level approval.
Understanding Medicare Rules for Ozempic Coverage
Medicare coverage of Ozempic depends on the medical reason it is prescribed.
Medicare Part D and Medicare Advantage plans may cover Ozempic when it is prescribed for an FDA-approved medical condition, such as type 2 diabetes, and when the drug appears on the plan’s formulary. Coverage may still involve prior authorization, step therapy, and varying out-of-pocket costs.
Medicare does not cover Ozempic when it is prescribed solely for weight loss. This exclusion is based on federal law and applies regardless of medical need, effectiveness, or provider recommendation.
Because prescription drug formularies and coverage rules can change each year, beneficiaries should review their plan details regularly and discuss covered treatment options with their healthcare provider to avoid unexpected costs and coverage gaps.