Does Medicare Cover Ozempic? What Part D Pays For (and What It Excludes by Law)

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> Reviewed by FormBlends Medical Team · Last updated May 2026 · 13 sources cited

As of May 2026. Confirm directly with your plan. Insurance coverage varies by employer plan, region, and time. Always confirm with your specific plan administrator.

Key Takeaways

• Medicare Part D covers Ozempic for type 2 diabetes. Coverage for weight loss is excluded by federal statute, not by plan choice
• The November 2024 CMS rule allows Part D coverage of GLP-1 medications for cardiovascular indication when prescribed for that purpose. This benefits Wegovy under the SELECT CV indication. Ozempic's Part D coverage scope is unchanged
• The 2025 Inflation Reduction Act $2,000 annual Part D out-of-pocket cap applies. For chronic GLP-1 patients, this dramatically changes annual cost
• The Novo Nordisk manufacturer savings card is not available to Medicare beneficiaries. The patient assistance program is the alternative
• Part D appeals go through a defined statutory path: Coverage Determination, Redetermination, IRE, ALJ, MAC, federal court. Most reversals happen at the IRE stage

Direct answer

Medicare Part D covers Ozempic for adults with type 2 diabetes when the plan's prior authorization criteria are met. Medicare Part D does not cover Ozempic for weight loss, because federal law (Social Security Act Section 1860D-2(e)(2)) excludes drugs used for weight loss from Part D. As of May 2026, the 2024 CMS rule on cardiovascular GLP-1 coverage has not changed Ozempic's coverage scope. Cost-sharing under Part D is now capped at $2,000 per year out-of-pocket across all covered drugs.

Table of contents

1. How Medicare Part D works for prescription drug coverage
2. The statutory exclusion of weight-loss drugs from Part D
3. What the November 2024 CMS rule actually changed
4. Part D PA criteria for Ozempic across major plans
5. Coverage phases and the new $2,000 out-of-pocket cap
6. The Novo Nordisk patient assistance program for Medicare patients
7. Low-Income Subsidy (Extra Help) and how to qualify
8. Part D appeals: the full statutory path
9. Medicare Advantage and Part D for Ozempic
10. Original Medicare and Ozempic: what's not covered
11. When Medicare won't cover: alternatives including 503A compounded
12. Contrary view: the case for Part D's weight-loss exclusion
13. Decision framework
14. FAQ
15. Sources

How Medicare Part D works for prescription drug coverage

Medicare Part D is the outpatient prescription drug benefit. Beneficiaries enroll in either a stand-alone Prescription Drug Plan (PDP) alongside Original Medicare, or a Medicare Advantage plan that includes Part D (MA-PD). The major Part D sponsors include Humana, UnitedHealthcare, CVS Caremark Silverscript, Aetna, Cigna, Wellcare, and others.

Each Part D plan publishes its own formulary, subject to CMS rules. The plan decides which drugs to cover, what tier they sit on, and what utilization management applies (PA, step therapy, quantity limits). CMS sets the floor: each plan must cover at least two drugs in each therapeutic class, and must cover substantially all drugs in six protected classes (which do not include diabetes drugs).

The statutory exclusion of weight-loss drugs from Part D

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003, which created Part D, excludes "agents when used for anorexia, weight loss, or weight gain" from Part D coverage. The exclusion is codified at Social Security Act Section 1860D-2(e)(2)(A).

This is a statutory exclusion, not a CMS policy choice or a plan decision. Part D plans cannot cover Ozempic, Wegovy, Saxenda, Zepbound, or any other drug when used for weight loss. The exclusion applies even if the plan would prefer to cover it.

The exclusion has been controversial since enactment. As GLP-1 medications have demonstrated cardiovascular and renal benefits beyond pure weight management, the question of whether weight-loss agents should be reclassified has grown. Congress has considered legislation to remove the exclusion (the Treat and Reduce Obesity Act has been introduced repeatedly), but as of May 2026, no enacted law has removed the exclusion.

What the November 2024 CMS rule actually changed

CMS finalized a rule in November 2024 that addressed the intersection of GLP-1 medications and Part D coverage. The rule clarified that when a GLP-1 medication is FDA-approved for a cardiovascular indication and prescribed for that purpose, Part D plans may cover it even if the medication is also approved for weight loss.

The practical effect is narrow:

• Wegovy. The FDA approved a cardiovascular indication for Wegovy in March 2024 based on the SELECT trial, which showed Wegovy reduced major adverse cardiovascular events in adults with overweight or obesity and established cardiovascular disease (Lincoff et al., NEJM 2023). Following the CMS rule, Part D plans began adding coverage for Wegovy when prescribed specifically for the CV indication.
• Ozempic. Ozempic is FDA-approved for T2D glycemic control and for cardiovascular risk reduction in T2D adults with established cardiovascular disease, based on SUSTAIN-6 (Marso et al., NEJM 2016). Ozempic is not approved for weight loss. The CMS rule did not change Ozempic's Part D coverage scope because Ozempic was already coverable for its existing indications.
• Mounjaro and Zepbound. The tirzepatide products. Mounjaro is approved for T2D and is coverable under Part D for that indication. Zepbound is approved for weight loss and obstructive sleep apnea. Coverage under the CMS rule depends on whether the cardiovascular outcomes data for tirzepatide produces an FDA-approved CV indication in the future.

The CMS rule is significant for Wegovy patients but does not expand Ozempic's coverage.

Part D PA criteria for Ozempic across major plans

Each Part D sponsor sets its own PA. The criteria converge on the same elements:

Element	Typical Part D requirement
Diagnosis	Type 2 diabetes (E11.x), documented
Age	18 or older
Prior therapy	Metformin trial, often 90 days at MTD, or documented contraindication
A1c	Recent value, sometimes minimum threshold
Step therapy	Plan-dependent, sometimes Trulicity preferred
Approval duration	12 months typically

The PA form is submitted by your prescriber to the Part D plan or its delegated PBM. Decisions arrive within 72 hours for standard requests, 24 hours for expedited.

Coverage phases and the new $2,000 out-of-pocket cap

The Part D benefit structure changed significantly with the Inflation Reduction Act. Effective January 1, 2025, Part D has three phases:

1. Deductible phase. You pay the full negotiated price up to the plan's annual deductible (maximum $590 in 2026).
2. Initial coverage phase. You pay a copay or coinsurance for each fill until your out-of-pocket spending reaches $2,000.
3. Catastrophic phase. Once you hit the $2,000 OOP cap, you pay $0 for the rest of the calendar year.

For Ozempic at retail prices around $1,000 per fill, hitting the OOP cap typically takes a few fills. Before 2025, the catastrophic phase had its own coinsurance and there was no annual cap. The change is meaningful for chronic GLP-1 therapy.

The Medicare Prescription Payment Plan (also from IRA) allows beneficiaries to spread the $2,000 OOP across the year in monthly installments rather than paying at the pharmacy counter.

The Novo Nordisk patient assistance program for Medicare patients

The Ozempic Savings Card is not available to Medicare beneficiaries. The Novo Nordisk patient assistance program (PAP) is the alternative.

PAP eligibility as of 2026 typically requires:

• U.S. residency
• Income at or below roughly 400% of the federal poverty level (confirm current threshold)
• No prescription drug coverage, or coverage that does not pay for Ozempic, or significant cost burden
• Prescription from a U.S.-licensed clinician

Approved patients receive Ozempic at no cost from the manufacturer through specific pharmacy partners. The program runs in 12-month enrollment periods with reapplication required at renewal.

For Medicare beneficiaries who exceed the PAP income threshold but cannot afford cost-sharing even with the new $2,000 cap, the State Pharmaceutical Assistance Programs (SPAPs) in some states provide additional help. Coverage varies by state.

Low-Income Subsidy (Extra Help) and how to qualify

The Low-Income Subsidy (LIS), known as Extra Help, reduces Part D costs for income-qualified Medicare beneficiaries. As of 2026, full LIS recipients pay copays of approximately $4.50 for generics and $11.20 for brand-name drugs (these amounts adjust annually).

Eligibility for full LIS as of 2026 typically requires:

• Income at or below 150% of the federal poverty level (the threshold expanded from 135% under the IRA)
• Resource limits on bank accounts, stocks, and bonds (homes and one vehicle do not count)

Apply through Social Security or your state Medicaid office. Many people who qualify do not apply. The application is short.

Part D appeals: the full statutory path

Part D appeals follow a structured path defined by federal regulation:

1. Coverage Determination. The initial request, filed by you or your prescriber with the Part D plan. Decision within 72 hours standard, 24 hours expedited.
2. Redetermination. First-level appeal, filed with the same plan. Decision within 7 days standard, 72 hours expedited.
3. Independent Review Entity (IRE). Second-level appeal, decided by C2C Innovative Solutions (the CMS contractor). Decision within 7 days standard, 72 hours expedited. Most appeal reversals happen here.
4. Administrative Law Judge (ALJ). Third-level appeal if the dispute meets the amount-in-controversy threshold (roughly $190 in 2026). Decision within 90 days.
5. Medicare Appeals Council. Fourth-level appeal. Decision within 90 days.
6. Federal District Court. Final level if the dispute meets a higher threshold (roughly $1,900 in 2026).

Most beneficiaries do not need to go past the IRE. Strong documentation at the Coverage Determination stage prevents many denials in the first place.

Medicare Advantage and Part D for Ozempic

Medicare Advantage plans with Part D (MA-PD) cover Ozempic for T2D under the Part D rules. Major MA-PD sponsors include UnitedHealthcare, Humana, Aetna, Cigna Healthspring, Wellcare, and Anthem's Medicare lines.

Tier placement and copay structure vary by plan. Some MA-PD plans place Ozempic on a preferred tier with lower copays. Others place it on a non-preferred tier. The $2,000 OOP cap and the Medicare Prescription Payment Plan apply across all MA-PD plans.

Original Medicare and Ozempic: what's not covered

Original Medicare (Parts A and B) does not include outpatient prescription drug coverage. Ozempic is not covered under Part A (hospital insurance) or Part B (medical insurance) for outpatient use.

Limited Part B coverage exists for drugs administered in a clinical setting under direct physician supervision. Ozempic is a self-administered subcutaneous injection. It is not covered under Part B even when initiated in a clinical setting.

Beneficiaries with only Original Medicare and no Part D plan pay cash for Ozempic unless they qualify for the patient assistance program. The Medicare Open Enrollment period each fall (October 15 to December 7) is the time to add a Part D plan or switch to MA-PD.

When Medicare won't cover: alternatives including 503A compounded

If Part D denies coverage, the realistic alternatives for Medicare beneficiaries are:

• The Novo Nordisk patient assistance program (income-qualified)
• Cash pricing with the Medicare Prescription Payment Plan to spread the cost
• State Pharmaceutical Assistance Programs where available
• 503A compounded semaglutide via telehealth (cash-pay, not billable to Medicare)

503A compounded semaglutide is the same active molecule as Ozempic but is not FDA-approved and is not equivalent to brand-name Ozempic. The product is prepared individually for each patient by a state-licensed 503A pharmacy. FormBlends works with state-licensed 503A pharmacies and licensed clinicians for clinically eligible patients.

For Medicare beneficiaries with T2D, the strong recommendation is to work the Part D PA process first, including appeals. Coverage is statutorily available and most denials reverse on a complete appeal. 503A compounded is a fallback, not a first choice.

Contrary view: the case for Part D's weight-loss exclusion

The Part D weight-loss exclusion has critics. The defense is rooted in 2003-era policy choices that reflected uncertainty about the long-term safety and effectiveness of weight-loss medications (the fen-phen withdrawal was less than a decade old when Part D was enacted) and concern about open-ended Medicare spending on lifestyle-adjacent drugs.

The argument for keeping the exclusion: Medicare spending on weight-loss drugs would be substantial. The Congressional Budget Office estimated removing the exclusion could cost roughly $40 billion over a decade. That cost gets paid by other beneficiaries through premiums and by taxpayers through trust fund spending.

The argument for removing it: the cardiovascular and renal benefits documented in SELECT and other trials suggest GLP-1 medications used for weight management are not "lifestyle drugs" in the way the 2003 exclusion contemplated. Obesity is a recognized chronic disease with documented Medicare cost implications through cardiovascular disease, kidney disease, and complications. Removing the exclusion is a policy debate that Congress, not CMS, has to resolve.

Decision framework

If you have T2D and Part D: file the PA. Coverage is generally available. Use the new $2,000 OOP cap to your benefit; if you have high drug spending, the cap limits annual exposure.

If you want Ozempic for weight loss on Medicare: the statutory exclusion blocks coverage. Wegovy may be available under the November 2024 CMS rule for the cardiovascular indication if you have established cardiovascular disease. Discuss with your clinician.

If you are low-income: apply for the Low-Income Subsidy (Extra Help). The application is short and the savings are substantial.

If you do not qualify for LIS and the Part D OOP is still burdensome: the Medicare Prescription Payment Plan spreads cost across the year. The Novo Nordisk PAP is another path for income-qualified patients.

If you are without Part D entirely: the next Medicare Open Enrollment is the time to add coverage. Until then, cash pricing or 503A compounded are the alternatives.

FAQ

Does Medicare cover Ozempic? For T2D yes through Part D. For weight loss no.

Did the 2024 CMS rule change Ozempic coverage? No. The rule expanded coverage for GLP-1 with a cardiovascular indication. Ozempic was already coverable for T2D and CV risk reduction in T2D. The rule benefits Wegovy more than Ozempic.

How much does Ozempic cost on Medicare? Copays vary; annual OOP is capped at $2,000 (2025 and later).

Can I use the Ozempic coupon on Medicare? No. Federal beneficiaries are excluded.

What about Extra Help? LIS recipients pay roughly $11.20 per brand-name fill as of 2026.

How do I appeal a Part D denial? Coverage Determination, Redetermination, IRE, ALJ, MAC, federal court.

What if I have only Original Medicare? No Part B coverage of Ozempic. Add Part D or MA-PD at the next Open Enrollment.

Sources

1. Social Security Act, Section 1860D-2(e)(2). Excluded drugs under Part D.
2. Centers for Medicare and Medicaid Services. Final rule on GLP-1 coverage for cardiovascular indications. November 2024.
3. Inflation Reduction Act of 2022. Part D out-of-pocket cap and price negotiation provisions.
4. U.S. Food and Drug Administration. Ozempic prescribing information.
5. U.S. Food and Drug Administration. Wegovy prescribing information including the SELECT cardiovascular indication.
6. Lincoff AM, et al. Semaglutide and cardiovascular outcomes in obesity without diabetes (SELECT). NEJM. 2023;389:2221-2232.
7. Marso SP, et al. Semaglutide and cardiovascular outcomes in T2D (SUSTAIN-6). NEJM. 2016;375:1834-1844.
8. CMS Medicare Prescription Payment Plan guidance. 2025.
9. Social Security Administration. Extra Help with Medicare prescription drug plan costs. 2026.
10. American Diabetes Association. Standards of Care 2026.
11. Congressional Budget Office. Estimates of removing the Part D weight-loss drug exclusion.
12. Novo Nordisk. Patient Assistance Program eligibility and application.
13. U.S. Food and Drug Administration. 503A compounding regulations.

Footer disclaimers

Platform Disclaimer. FormBlends is a telehealth platform that connects patients with licensed clinicians. We do not enroll beneficiaries in Medicare plans or adjudicate Medicare claims. Information about Part D rules reflects publicly available materials as of May 2026.

Compounded Medication Notice. Compounded semaglutide is prepared by a state-licensed 503A pharmacy for an individual patient. It is not FDA-approved, is not equivalent to brand-name Ozempic, and is not billable to Medicare or any federal program. Decisions about compounded medication should involve a prescribing clinician.

Results Disclaimer. Coverage outcomes, copays, and appeal results depend on individual plan rules and documentation. Examples in this article are illustrative.

Trademark Notice. Ozempic, Wegovy, and Rybelsus are registered trademarks of Novo Nordisk A/S. Mounjaro and Zepbound are registered trademarks of Eli Lilly and Company. Trulicity is a registered trademark of Eli Lilly and Company. Medicare is a federal program administered by CMS. FormBlends is independent and not affiliated with these entities.