Does TRICARE cover Ozempic?

If you get your health insurance through the US military, you might wonder, "Does TRICARE cover Ozempic?" The answer is often yes — so long as you're an eligible patient with type 2 diabetes (T2D).

Keep reading to learn more about TRICARE's rules for Ozempic coverage, the cost of Ozempic with TRICARE, and what you can do if you don't qualify for coverage. 

Yes, but it depends on the reason for your prescription.  

TRICARE covers Ozempic (semaglutide) when it’s prescribed for diabetes and you meet coverage requirements.

It won’t cover Ozempic when it's prescribed outside of the uses the drug is approved for by the US Food and Drug Administration (FDA). All of Ozempic's FDA-approved uses, including lowering cardiovascular risk and slowing chronic kidney disease (CKD), apply only to adults with type 2 diabetes. TRICARE won’t cover Ozempic for off-label uses like fatty liver or weight loss.

Though TRICARE recently narrowed coverage of the weight loss drugs Zepbound and Wegovy, it still typically covers the GLP-1s Ozempic, Mounjaro, and Trulicity for diabetes. And unlike the VA's Ozempic coverage, TRICARE isn't strict about whether you take the oral or injectable versions of Ozempic.

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TRICARE coverage for Ozempic: rules and criteria 

Here are TRICARE's coverage requirements for Ozempic:

• A T2D diagnosis. Ozempic has three FDA-approved uses in people with type 2 diabetes — managing blood sugar levels, lowering cardiovascular risk, and reducing CKD-related decline.

• Prior approval. TRICARE's Ozempic coverage isn't automatic. Your healthcare provider must first submit documentation confirming that you need Ozempic to regulate your blood sugar.

• Step therapy. Your provider must also confirm that you've tried (and failed) to control blood sugar with metformin (a less costly medication) or cannot take metformin for medical reasons.

Yes. TRICARE always requires prior authorization  for Ozempic.

Prior authorization means TRICARE won't cover Ozempic until your healthcare provider has sent documentation confirming the following: 

1. You've been diagnosed with type 2 diabetes.

2. You fall into one of these three categories:

• You've tried metformin, but it hasn't adequately controlled your blood sugar.

• You've tried metformin but experienced kidney problems or have a history of lactic acidosis.

• You can't take metformin for medical reasons.

Prior authorization may seem like a hassle, but it's a common requirement for GLP-1 insurance coverage. These medications are expensive, so TRICARE and other insurers want proof that you need Ozempic in place of a more affordable alternative.

If approved, Ozempic costs $0–$48 per month with TRICARE. 

With TRICARE, your monthly out-of-pocket cost depends mostly on whether you're a full-time military service member.

• Active duty members pay $0 per month for Ozempic.

• Non-active duty enrollees pay $0 per month for Ozempic at their local military pharmacy (if carried), $44 for home delivery, or $48 from a retail pharmacy. 

Those out-of-pocket prices do not change based on Ozempic dosage strength or whether you take Ozempic as a weekly shot or daily pill.

The list price of Ozempic without insurance is just over $1,000 per month. That said, every person’s out-of-pocket costs can vary by pharmacy, location, and manufacturer savings or coupons. 

All TRICARE plans cover Ozempic for eligible enrollees. The question is whether TRICARE will cover your Ozempic prescription. 

Remember:

• You must have a type 2 diabetes diagnosis.

• You must have a prior authorization from your provider, which may be denied if you don't have uncontrolled blood sugar or if you have not already tried metformin.

To verify this information, you can check the TRICARE formulary, a list of covered drugs. Type "Ozempic," then select your dose, biological sex, and age from the dropdown menus, and click "Search." You will see that Ozempic is covered "with limitations," referring to the criteria explained above.

Still unsure? Call your TRICARE rep for personalized information, or have your healthcare provider request a coverage review at 1-866-684-4488.

If TRICARE won't cover your Ozempic prescription, you have a few options.

1. Pay out of pocket. You can get Ozempic without insurance, but you'll pay out of pocket. Without discounts, the list price for Ozempic is $1,027.51.

2. Try a different diabetes medication. TRICARE still requires prior authorization for Trulicity, but notes that it may cost less than Ozempic. Other covered medications for diabetes include metformin and Jardiance (without prior authorization), and Mounjaro (with prior authorization).

3. Consider Medicare Part D, if eligible. This doesn't apply to everyone, but some people on TRICARE can also sign up for Medicare Part D. In many cases, Medicare covers Ozempic for FDA-approved uses, including diabetes and cardiovascular risk reduction. 

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Does TRICARE cover Ozempic? Yes, depending on why you're taking it and whether you've met coverage criteria.

• TRICARE only covers Ozempic for people diagnosed with type 2 diabetes. Plans don't cover Ozempic for weight loss or other off-label uses.

• TRICARE requires prior authorization for Ozempic. Your healthcare provider must provide documentation of your T2D diagnosis and medical need for Ozempic.

• With TRICARE coverage, Ozempic costs less than $50 per month. You'll pay $0–$48, depending on your pharmacy and whether you're active duty.

• You have options if TRICARE won't cover Ozempic. You can pay for Ozempic out of pocket, switch to a different diabetes treatment, or consider signing up for Medicare Part D (if you're eligible).