Is Ozempic Covered By Blue Cross Blue Shield?
Yes.
Generally for type 2 diabetes, but not for weight loss unless specific criteria are met.
Blue Cross Blue Shield (BCBS) coverage varies since BCBS is composed of 33 independent plans, but members are typically covered for Ozempic when prescribed for type 2 diabetes, with prior authorization required.
Does Ozempic Require Prior Authorization?
Yes.
BCBS plans almost universally require prior authorization for Ozempic. Providers usually need to submit:
- A diagnosis of type 2 diabetes
- Evidence of inadequate response to other diabetes medications (e.g. metformin)
- Recent A1c or glycemic control data
- Records of lifestyle interventions
Are There Coverage Restrictions?
Yes.
Restrictions may include:
- Quantity limits (typically one pen per month)
- Step therapy, requiring metformin before advancing to Ozempic
- Tier placement (often Tier 3–4) impacting your copay or coinsurance
Is Ozempic Covered for Weight Loss?
Rarely.
Coverage for weight loss (off-label use) is uncommon and typically denied unless:
- Diagnosed with obesity (BMI ≥30 or ≥27 with comorbidity)
- Documented history of unsuccessful lifestyle interventions
- Appeal includes medical necessity rationale
What Documentation Is Needed?
Include:
- Recent A1c and BMI measurements
- History of treatment with metformin or other agents
- Records of lifestyle interventions
- Letter of medical necessity outlining rationale for Ozempic
What If Coverage Is Denied?
You can appeal with updated documentation:
- New clinical notes
- Additional lab results
- Medical necessity statement submitted by your provider
Where to Get More Info
- BCBS formulary and steps for prior authorization vary by state and plan.
- Check your Member Portal or call customer service for details specific to your plan.
- Explore the BCBS member website for more information.
FAQ: BCBS and Ozempic Coverage
Does BCBS cover Ozempic for diabetes?
Yes. Most plans cover it with prior authorization when prescribed for type 2 diabetes.
Is prior authorization always required?
Yes. Expect to submit diagnosis, A1c levels, and previous meds.
Will it cost a lot out-of-pocket?
Typically placed in Tier 3 or 4, so copays or coinsurance apply—your plan details will clarify.
What if I use it for weight loss?
Coverage is unlikely; consider using Wegovy (approved for weight loss) instead.
Do BCBS plans sometimes stop covering weight-loss drugs?
Yes. Some state plans are rolling back weight-loss drug coverage entirely.
Related pages: Ozempic, Zepbound, Mounjaro, Saxenda, Qsymia, Contrave
Medical Disclaimer
This information is for educational purposes only and is not medical advice. Coverage can vary widely by BCBS plan and location. Always consult your healthcare provider and insurer for personalized guidance.