Introduction
So you’ve decided to take semaglutide. Whether for type 2 diabetes or weight management, clinical trials have proven it to be safe, effective, and tolerable.
As reliable as semaglutide may be, not everyone may be able to afford it or keep paying for it. This holds true especially those who take it to manage chronic conditions. We’re sure you’ve thought to yourself, ‘Is semaglutide covered by insurance?’ ‘Which semaglutide is covered by insurance?’
Let’s explore insurance coverage, costs, and factors that influence semaglutide coverage.
What is semaglutide?
Why are semaglutide brands like Ozempic and Wegovy such a hit and how do they work? It lies in its composition.
Semaglutide is a glucagon-like peptide-1 receptor agonist, or GLP-1 Ra, for short. Whenever we finish eating and blood sugar levels are high, it kicks into action just like the natural gut-based GLP-1.
Just like GLP-1, semaglutide prompts the pancreas to secrete just the right amount of the hormone insulin. Insulin brings down the high blood sugar levels.
On top of this, semaglutide also delays gastric emptying, when food exits the gut and enters the small intestine. Because of the slower digestion, you tend to feel fuller for longer and you don’t think of food as much. With fewer food cravings, you end up losing weight. Semaglutide also sends signals to the brain that you’re full.
Eligibility
Semaglutide isn’t a drug that just anyone can take. You have to first meet certain diagnostic criteria before you can be eligible for it. They also need to first secure a prescription before availing of Ozempic or its sister semaglutide brands, Wegovy or Rybelsus.
To take Ozempic or Rybelsus, you must have type 2 diabetes, which they have FDA approval to treat. Doctors may also prescribe Ozempic for those with heart disease. This is because it has additional approval for lowering the risk of cardiovascular problems. Healthcare providers may also at times prescribe them for those dealing with insulin resistance.
Wegovy, on the other hand, has FDA approval to treat obesity. To take it, you need to have a body mass index (BMI) of at least 27 or greater. Additionally, you must have one weight-related health condition (ex: high blood pressure), or a BMI of 30 or greater.
Although the manufacturer Novo Nordisk markets Ozempic and Wegovy for different uses, they are both essentially semaglutide. Hence, they offer the same therapeutic benefits of blood sugar regulation and weight management. This is why many doctors choose to prescribe Ozempic or Rybelsus off-label for weight loss.
Oral and subcutaneous semaglutide
Before you get your supply of semaglutide, you’ll need to decide between its two formats: oral or subcutaneous semaglutide.
People call Rybelsus oral semaglutide as it comes in tablet format and you must take it orally. Ozempic and Wegovy, meanwhile, are referred to as subcutaneous semaglutide. It comes in injectable dosing pens and you inject it under the skin.
Dosage and administration
To maximize the benefits of semaglutide, patients must observe its proper dosage and administration. Your healthcare provider will typically start you on a low dose before gradually increasing this as your body adjusts.
You can inject both Ozempic and Wegovy in three different sites: the 1) abdomen, 2) thigh, or 3) upper arm. You must administer it once weekly, regardless of meals.
It’s best to use a different injection site with every injection. But if you want to use the same injection site, pick a different spot in that area to prevent irritation. Make sure that you are not injecting into a muscle or vein. For Rybelsus, on the other hand, you must take it on an empty stomach once daily.
Does insurance cover semaglutide?
Several factors can affect whether insurance will cover Ozempic or Rybelsus or not. For example, what condition did the doctor note in the prescription? Which pharmacy did you source it from? Not to mention, your health insurance plan’s coverage, too.
Generally, your health insurance will likely cover Ozempic or Rybelsus if the prescription is for type 2 diabetes. Note, though, that you may need to pay a copay (co-payment). This is a standard fee that you pay for a healthcare service under some insurance plans.
If prescribed for weight loss, on the other hand, your insurance provider may not cover Ozempic or Rybelsus. This is the case unless you’re taking them for a weight-related health problem.
Insurance doesn’t always cover Wegovy and weight loss drugs, meanwhile, because many consider them “lifestyle” or “vanity drugs.” Some providers cover it, others if you meet certain requirements, and others not at all.
Despite weight loss proving to improve overall health outcomes, many insurance companies still do not cover GLP-1 medications.
So which semaglutide does insurance cover?
Insurance may cover all semaglutide, but this depends on the individual health insurance provider’s coverage terms.
If for treating type 2 diabetes, your insurance company will likely cover semaglutide. But the same cannot be said for FDA-approved drugs like Wegovy and semaglutide prescribed off-label for weight management.
How the US health insurance coverage works
Employers commonly cover most Americans with health insurance through a split contribution shared between employer and employee. Those who don’t have access to employer-sponsored plans, meanwhile, can buy individual or family health insurance plans.
With semaglutide, the coverage will largely depend on the patient’s health insurance plan and individual insurance policy. Although it may be possible for insurance to cover the drug, the coverage may not be 100%. There may be times when you may need to pay part of the cost.
Checking your semaglutide coverage
To check if your insurance covers your semaglutide injection, you can simply visit the Ozempic, Wegovy, and Novo Medlink websites. Simply answer a questionnaire, share your patient information, and look up your health insurance provider. You can also review your health insurance policy documents or consult your insurance agent.
Non-coverage of semaglutide
Insurance companies don’t typically cover weight loss drugs as they perceive obesity as a cosmetic issue than a chronic disease. Weight loss medications also have hefty price tags, with a month’s supply easily going beyond $1,000 a month.
In 2023, only one in every four employers covered GLP-1 weight loss drugs. These employers, however, are tightening the criteria for their eligibility.
Another hindrance to the coverage of semaglutide injections is a 2023 law that prevents Medicare from covering weight loss medications. Medicare is the US federal health insurance for citizens aged 65 or older.
Ironically, those who succeeded in their semaglutide treatments using semaglutide were suddenly denied coverage for the medication.
Weight loss drugs may still be covered
There’s still a chance that semaglutide may be fully covered by insurance, even for weight loss purposes. A growing number of companies are planning on incorporating weight loss drugs as part of their health plans in 2024.
Proving weight loss drugs’ benefits beyond diabetes and obesity
Semaglutide’s manufacturer, Novo Nordisk, and weight loss drug Mounjaro’s manufacturer, Eli Lilly, are fast-tracking certain trials. These trials aim to prove their benefits beyond type 2 diabetes and obesity. In this way, it will be easier for patients to get access to the expensive medicine that they need.
Additionally, clinical trials are in progress to see whether the drugs can lower the risk of certain diseases. These include heart attack, kidney disease, stroke, and other chronic diseases typically afflicting those suffering from obesity.
In August 2023, Novo Nordisk found that Wegovy cut the risk of cardiovascular problems like heart attack and stroke by 20%.
Despite semaglutide’s success rate in improving blood pressure and cholesterol, the FDA requires heart health standalone studies before concluding benefits. In October 2023, Novo Nordisk announced that semaglutide slowed the development of kidney disease in patients with type 2 diabetes.
The Treat and Reduce Obesity Act
In 2021, lawmakers introduced The Treat and Reduce Obesity Act. It would have allowed the federal government to expand Medicare’s coverage to include weight loss drugs. Although the act received 154 co-sponsors, it did not receive a vote on the House floor before the term ended.
The Congressional Budget Office said that it is calling for new research to support the use of weight loss drugs under Medicare. They are also keen to review the potential savings it could provide.
Big long-term savings for weight loss drugs
Research presented at the 2023 Obesity Week found that HR executives and benefits consultants thought positively of weight loss drugs. Furthermore, they agreed that these can help their employees enhance their overall quality of life. The data also revealed that they were interested in reviewing more information that would justify such high-cost coverages.
Economists are also pointing out that though weight loss drugs may be expensive, these may lead to significant savings. This is if they prevent the risk of heart problems like cardiovascular deaths, heart attacks, and strokes.
An analysis estimated Medicare could save $175 billion in 10 years if it covered new weight loss drugs like semaglutide. US society as a whole could also save up to $1 trillion if all eligible Americans were treated with them.
Unfortunately, insurance companies are hesitant to cover weight loss drugs because their long-term effects and benefits are still unknown.
Conclusion
All semaglutide brands—Ozempic, Wegovy, or Rybelsus—may or may not be covered by insurance providers. Semaglutide coverage varies by insurance provider, condition treated, and the prescribed brand.
While Ozempic or Rybelsus may get covered for diabetes, Wegovy faces challenges due to its weight loss drug classification. Likewise, Wegovy’s coverage will depend on the plan as many providers consider weight loss drugs as for cosmetic purposes only.
Drug manufacturers are fast-tracking trials that will prove weight loss drugs’ benefits beyond diabetes and obesity. Hopefully, this will lead to greater insurance coverage in the future. From an economic standpoint, such data may also be beneficial in creating big long-term savings for federal health insurance programs.
Despite these advances, many insurance providers are hesitant to cover semaglutide and similar GLP-1 drugs. This is because their long-term effects and benefits of weight loss drugs are still unknown.
Glossary of terms:
- GLP-1: Glucagon-like peptide-1 is a gut-based hormone involved in the secretion of insulin to lower blood sugar levels typically elevated after meals.
- GLP-1 Ra: Glucagon-like peptide-1 receptor agonist. It mimics the actions of GLP-1.
