Does Anthem cover Ozempic?

If you are considering Ozempic (semaglutide) and have an Anthem Blue Cross Blue Shield insurance plan, you are probably wondering, "Does Anthem cover Ozempic?" The answer may depend on your plan and reason for your Ozempic prescription.​

Learn more about Anthem's coverage for Ozempic for type 2 diabetes and weight loss.

Sometimes. Anthem's Ozempic coverage varies by plan and why you are taking this GLP-1 — similar to coverage through Kaiser, United Healthcare, or Medicare.

Anthem plans generally cover Ozempic for type 2 diabetes. The US Food and Drug Administration has approved Ozempic for three uses:​

1. Blood sugar control in people with type 2 diabetes

2. Cardiovascular risk reduction in people with heart disease and type 2 diabetes

3. Kidney disease and cardiovascular risk reduction in people with chronic kidney disease and type 2 diabetes

Ultimately, Anthem plans may cover Ozempic when it is prescribed for an FDA-approved reason. When Anthem plans do cover Ozempic, it is usually classified as a Tier 2 medication with a higher copay. Prior authorization is also typically required.

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Does Anthem cover Ozempic for weight loss?

No, Anthem does not usually cover Ozempic for weight loss. Similar to Ozempic for fatty liver, weight loss is an off-label — meaning not FDA-approved — use of the medication. Ozempic coverage varies by specific plan and prescription purpose, but it is unlikely to be covered for weight loss.

Yes, you need prior authorization for Ozempic on Anthem.

Prior authorization means that your healthcare provider must submit paperwork to Anthem confirming why Ozempic is medically necessary for you. In all cases, Anthem only covers Ozempic if you are an adult with a type 2 diabetes diagnosis.

Anthem's other clinical criteria are a history of one or more of the following:

• HbA1c level of 6.5% or more

• Fasting plasma glucose (FPG) of 126 mg/dL or higher

• 2-hour plasma glucose (PG) of 200 mg/dL or higher during an oral glucose tolerance test

• Random plasma glucose of 200 mg/dL or higher, with signs of hyperglycemia (high blood sugar)

And one or more of the following:

• An unsuccessful trial of metformin treatment

• A contraindication to metformin treatment

• A history of atherosclerotic cardiovascular disease

• A diagnosis of chronic kidney disease

According to Anthem, most prior authorization requests are approved within 72 hours after the company receives the necessary documentation from your healthcare provider.

Prior authorization for Ozempic for weight loss on Anthem

Anthem does not outline prior authorization criteria for Ozempic for weight loss because it will not cover Ozempic for weight loss alone.

If you are enrolled in an Anthem plan and want Ozempic for weight loss, your best option for coverage is to also meet the criteria above. In that case, your healthcare provider would prescribe it to treat diabetes, not for weight loss, and the weight loss would be an added benefit.

Anthem is an independent licensee of the Blue Cross Blue Shield Association, and it offers dozens of commercial and individual insurance plans. Here is how to find out whether your Anthem plan covers Ozempic:

1. Check your medication formulary. Sign in to your Anthem member account to view your plan's prescription drug formulary (the list of covered medications). Search "Ozempic" to see if the medication is on the list.

2. Call Anthem directly. The number on the back of your insurance card connects you with a representative who can check your prescription coverage and walk you through any requirements for Ozempic coverage.

3. Use Ro’s free GLP-1 insurance coverage checker. If interested in the Ozempic injection, enter your insurance information into the online tool, and Ro will check your plan and provide a personalized report with your coverage details.

Ozempic is available as both a weekly injection and a once-daily pill. Pricing and coverage criteria can differ by formulation.

The list price for the Ozempic injection is $1,027.51 for a 28-day supply. Your out-of-pocket cost depends on factors such as insurance coverage and pharmacy.

If your Anthem plan covers Ozempic, it may have a higher copay as a Tier 2 medication. The manufacturer savings offer (if you are eligible) can lower that copay to as little as $25 per month.

Without insurance, the Ozempic pill costs $149 per month at the starting dose for new patients through NovoCare, Novo Nordisk's savings program.

If Anthem will not cover Ozempic, you can still pay for your prescription.

1. Opt for self-pay. You can still get Ozempic without insurance, but you will pay more. The list price for the injection is more than $1,000 per month, while the pill costs less to start. Sites such as GoodRx, SingleCare, and BuzzRx also offer free Ozempic coupons. (Participation varies by pharmacy.)

2. Switch insurance plans. If your Anthem plan will not cover your Ozempic prescription, switching plans might help. Pay attention to open enrollment deadlines, because you typically cannot switch insurance plans without a major life event.

3. See if Anthem will cover a different, similar medication. Other injectable GLP-1s for weight loss include Wegovy (semaglutide) or Zepbound (tirzepatide). Other oral GLP-1s include Foundayo (orforglipron). For diabetes alternatives, talk to your healthcare provider about Mounjaro (tirzepatide).

Start your journey

Anthem's Ozempic coverage comes down to one key distinction: diagnosis. Prescribed for type 2 diabetes, coverage is common. Prescribed for weight loss alone, coverage is rare.

Here is what to remember about Anthem's coverage of Ozempic:

• Anthem typically covers Ozempic for adults with type 2 diabetes. But you will need prior authorization, and you might need to try a cheaper diabetes treatment such as metformin first.

• Anthem is unlikely to cover Ozempic for weight loss. Ozempic is not FDA-approved as a weight loss injection or pill, and most insurers cover medications only for their approved purposes.

• You can find out if and when your Anthem plan covers Ozempic. Sign in to the member portal, call the number on the back of your insurance card, or try Ro's free GLP-1 insurance coverage checker.

• With insurance, the monthly cost of Ozempic varies by plan. But your monthly copay can be as low as $25 with Anthem coverage and the manufacturer savings offer.

• Without insurance, Ozempic costs range from $149 to more than $1,000 per month. Look into manufacturer savings programs and free coupons — or consider switching medications or insurance plans if needed.