Does Blue Cross Blue Shield cover Ozempic?

Given its benefits for type 2 diabetes, weight loss, and more, Ozempic (semaglutide) is a highly sought-after medication. However, it’s also expensive, with an almost $1,000 per month out-of-pocket price tag.

Getting insurance coverage for Ozempic isn’t as clear-cut as some other medications, and can depend on what you’re taking it for as well as your plan’s specific coverage options. Here’s what you need to know about whether Blue Cross Blue Shield (BCBS) covers Ozempic.

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“It depends on the specific plan, which is negotiated between the employer and the payer,” shared Dr. Beverly Tchang, MD, an endocrinologist who treats patients with obesity, and is an advisor to Ro. Ultimately, whether BCBS covers Ozempic isn’t a straightforward answer. It can depend on several factors, from your plan’s specific coverage details to whether you’re taking it for type 2 diabetes or off-label for weight loss. 

BCBS is a network of over 60 independent insurance companies and licensees, including Blue Cross, Blue Shield, Blue Cross and Blue Shield, Anthem, Highmark, CareFirst, and others. Each of these has its own unique policies and coverage options—which can be updated at any time. Several factors can determine if your specific BCBS plan covers Ozempic, and how easy (or cheap) it is to get Ozempic.

Diagnosis

Insurance coverage for Ozempic may depend on whether your diagnosis, meaning the medical condition identified by your healthcare provider, aligns with the specific uses the FDA has approved the drug to treat.

If an insurer covers a medication, it’s typically for their FDA-approved indications, shared Dr. Tchang. In the case of Ozempic, that means type 2 diabetes. Ozempic’s FDA-approved indications are to improve blood sugar control in people with type 2 diabetes, or to reduce cardiovascular risk in people with type 2 diabetes and heart disease.

Ozempic is not FDA-approved for weight loss. So, when healthcare providers prescribe Ozempic for weight loss, they are doing so off-label (meaning that it’s being prescribed for a condition other than the FDA-approved indication). Off-label prescriptions are a lot less likely to be covered by insurance plans, including those offered by Blue Cross Blue Shield. 

There is another medication made by Novo Nordisk that contains the same active ingredient (semaglutide) as Ozempic: Wegovy. Wegovy is FDA-approved for weight loss, so some insurance plans, including BCBS, may be more likely to cover Wegovy for weight loss vs. Ozempic. 

Drug tier

Like other insurance plans, BCBS organizes its list of covered drugs, also known as a formulary, into several tiers. BCBS drug tiers may include:

• Tier 1: Preferred generic drugs

• Tier 2: Generic drugs

• Tier 3: Preferred brand drugs

• Tier 4: Non-preferred brand drugs

• Tier 5: Specialty drugs

• Tier 6: Non-preferred specialty drugs

Or, your plan’s list of drug tiers might be simpler, such as:

• Tier 1: Generic drugs and low-cost, preferred-brand drugs

• Tier 2: Non-preferred generic drugs or preferred brand drugs

• Tier 3: Non-preferred brand drugs or drugs that usually have a cheaper equivalent on a lower tier

• Tier 4: Specialty drugs

If that all feels like a lot of mumbo jumbo, welcome to the wonderful world of prescription drug coverage! Here’s the key thing you need to know: the higher the tier, the higher the cost. In other words, you’ll usually pay more for a Tier 4 drug than a Tier 1 drug. 

Ozempic typically falls somewhere in the middle. It’s a Tier 3 Preferred Brand drug on the BlueMedicare PPO Enhanced plan offered by BlueCross BlueShield of North Carolina. Meanwhile, it’s a Tier 2 Preferred Brand drug on various HMO and PPO plans offered by Blue Shield of California.

Prior authorization

Some insurance plans don’t cover certain medications outright; they require prior authorization. That means you’ll need to work with your healthcare provider to submit paperwork to BCBS requesting that they cover Ozempic. 

“Prior authorizations vary from one insurance plan to the next; it may be one question long or two pages long,” shared Dr. Tchang. “Usually a document needs to be filled out by the prescriber or the prescriber's staff that confirms the patient's eligibility for the medication.”

BCBS typically requires prior authorization for Ozempic. You can check if your specific plan does by reviewing your plan’s drug formulary. If you see a “PA” next to Ozempic, that means prior authorization is required. 

It’s worth noting that submitting the paperwork doesn’t always result in approval. Your BCBS insurance plan may choose to deny your request and not cover Ozempic, leaving you paying out of pocket for the medication. But, if they do deny it, you can always try again and submit an appeal.

The list price of Ozempic is $968.52 for a 30-day supply, according to Novo Nordisk, the maker of Ozempic. However, the list price is set by the manufacturer, and you may pay more—or less—depending on your insurance coverage, the pharmacy you use, and whether you’re eligible for any Ozempic coupons or savings programs.

Checking whether your BCBS plan covers Ozempic can take a little effort. You can review your plan’s drug formulary, but these get updated regularly, and may even change from month to month. Check the date on the formulary to make sure you are looking at the most recent version. You can also contact your BCBS plan directly and ask them. 

Novo Nordisk offers a free tool to check insurance coverage for Ozempic through their NovoCare program. You can call 1‑844‑Novo4Me (1‑844‑668‑6463) or fill out the online form here and an agent will get back to you with the coverage information they found. The service is available weekdays from 8 a.m.–11 p.m. and Saturday from 11 a.m.–7 p.m. Eastern Time. Have your insurance card handy.

If you are prescribed Ozempic through the Ro Body Program, Ro’s insurance concierge offers a similar service. They will verify your benefits through BCBS and work with your BCBS provider to get Ozempic covered for weight loss. 

If you can’t receive coverage for Ozempic through your BCBS plan, don’t despair. They may cover an alternative medication instead, such as Mounjaro (tirzepatide), Trulicity (dulaglutide), or metformin or compounded semaglutide. Review your coverage options and talk with your healthcare provider to see what your best next steps are.

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Every article on Health Guide goes through rigorous fact-checking by our team of medical reviewers. Our reviewers are trained medical professionals who ensure each article contains the most up-to-date information, and that medical details have been correctly interpreted by the writer.

Current version

July 18, 2024

Written by

Amelia Willson

Fact checked by

Patricia Weiser, PharmD

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About the medical reviewer

Patricia Weiser, PharmD

Patricia Weiser, PharmD, is a licensed pharmacist, health content writer, and medical reviewer with more than a decade of clinical experience in community and hospital pharmacy.