Does Anthem cover Ozempic

If you’re enrolled in an Anthem Blue Cross Blue Shield plan and are considering Ozempic (semaglutide) for type 2 diabetes, you may be wondering—does Anthem cover it? In this guide, you’ll learn about Anthem’s eligibility criteria, how to check your plan’s coverage, online prescription options, reasons for possible denials, tips for improving your chances of approval, cost-saving alternatives, and how to request prior authorization. 

Ready to understand your benefits and explore your treatment options? Book a visit on Klarity Health for personalized support.

Does the Anthem cover Ozempic?

Anthem may cover Ozempic when it’s prescribed to treat type 2 diabetes, because it’s approved by the U.S. Food and Drug Administration (FDA) to improve blood sugar control in adults with type 2 diabetes. However, Anthem typically doesn’t cover off-label uses, meaning treatments for which it’s not FDA-approved, such as weight loss. 

 Coverage usually requires prior authorization, including documentation of a Type 2 diabetes diagnosis, recent A1C results, and evidence that other diabetes medications (such as metformin or sulfonylureas) have not adequately controlled blood sugar.  Coverage terms vary by plan, and Ozempic is often listed in a higher-cost formulary tier, which can impact your out-of-pocket costs.

Eligibility criteria for Anthem coverage for Ozempic

Anthem includes Ozempic on its formulary, or list of covered prescription drugs, in most states, including California. But remember, coverage is generally limited to FDA-approved uses—specifically, for managing type 2 diabetes, reducing major cardiovascular events, or slowing the progression of chronic kidney disease (CKD) in adults with type 2 diabetes.

Coverage usually requires prior authorization and documentation such as a confirmed diagnosis of type 2 diabetes, recent A1C results, and evidence that first-line treatments like metformin haven’t been effective. Patients may also need to demonstrate that they’ve tried recommended lifestyle changes, such as a healthy diet and regular exercise. Ozempic is often listed in a higher-cost formulary tier (Tier 2), and specific coverage terms, including quantity limits, can vary by plan and state.

Not sure if your insurance covers Ozempic?

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How to know whether my Anthem covers Ozempic?

There are a few ways you can find out if your Anthem insurance plan covers Ozempic. Including: 

1. Review Anthem’s drug formulary
Anthem publishes state-specific lists of covered drugs online.

• Log in to your Anthem member account
• Go to: Pharmacy and then Drug List/Formulary
• Search for “Ozempic” to view its tier placement and coverage details

2. Call Anthem Pharmacy Services
Use the number on your Anthem ID card and ask:

• Is Ozempic included in my formulary?
• Do I need prior authorization?
• What is the copay or coinsurance under my plan?

3. Use the “Price a Medication” tool
Anthem’s online pricing tool can help estimate out-of-pocket costs based on your plan benefits.

Does Anthem cover an Ozempic prescription online?

You can be prescribed Ozempic through telehealth platforms such as Klarity Health, and it will usually be covered by Anthem. If a licensed provider determines it is medically necessary, you can fill your online Ozempic prescription at a participating retail or mail-order pharmacy.

Many telehealth services also assist with prior authorization, helping you avoid unnecessary delays and paperwork.

Check if Ozempic is covered by your insurance

Speak with a provider through Klarity to review your benefits and see if Ozempic is the right fit for your treatment.

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Why Anthem might deny Ozempic coverage

Even if Ozempic is listed on your plan’s formulary, coverage may be denied due to:

• Off-label use — Prescriptions for weight loss or prediabetes typically do not qualify
• Insufficient documentation — Lack of proof of type 2 diabetes or lab values like HbA1c
• Step therapy requirements — Failure to try lower-tier medications, such as metformin
• High dosing — Weekly doses exceeding 2 milligrams are not FDA-approved and may be rejected
• Non-participating pharmacy — Filling prescriptions outside Anthem’s pharmacy network
• Incomplete prior authorization — Missing forms or clinical information may result in denial

Tips for improving your chances of Ozempic approval

While your chances of getting coverage for Ozempic are good if you meet the eligibility requirements, claims can still be denied. To avoid rejections or slowdowns in processing your prescription, consider: 

1. Providing lab results showing elevated HbA1c or uncontrolled type 2 diabetes
2. Documenting any previous medications you’ve tried, such as metformin
3. Highlighting additional conditions like cardiovascular disease or CKD
4. Ensuring the prior authorization includes all required clinical notes and records
5. Considering using a telehealth service like Klarity Health to manage the entire submission
6. Following up regularly, prior authorization decisions may take several business days to 30 days
7. If denied, consider filing an appeal. Ozempic alternatives and savings if Anthem doesn’t cover Ozempic

If Anthem denies coverage for Ozempic, you may want to explore other GLP-1 receptor agonists or savings programs:

Covered alternatives for Ozempic include: 

• Wegovy® (semaglutide 2.4 milligrams) – FDA-approved for weight management
• Mounjaro® (tirzepatide) and Saxenda® (liraglutide) – FDA-approved for weight loss
• Rybelsus®, Trulicity®, Victoza® – GLP-1 receptor agonists approved for type 2 diabetes

Savings and assistance programs that may help lower costs include:

• Novo Nordisk savings card – May reduce cost to as low as $25 for commercial plans
• Patient Assistance Programs – Offer free or discounted medication for uninsured users
• NovoCare support tools – Help calculate out-of-pocket costs and access financial aid
• GoodRx coupons – May save up to $235 or more monthly, depending on pharmacy pricing

How to get prior authorization from Anthem for Ozempic

In most cases, your provider can facilitate the prior authorization process for you. But, to start the process:

1. Contact Anthem or log in to your portal to confirm prior authorization requirements.
2. Ask your provider to complete and submit Anthem’s PA form, including:
   • Diagnosis (type 2 diabetes) and comorbidities
   • Current HbA1c or blood glucose levels
   • Documentation of prior therapies (e.g., metformin)
   • Proposed dosage and treatment plan
3. Submit electronically via your provider or pharmacy portal
4. Follow up with Anthem if needed.  Prior authorization decisions can take a few days to several weeks
5. Appeal if denied, including additional documentation or clarification from your provider

Book an appointment on Klarity Health

Anthem may cover Ozempic for managing type 2 diabetes, but off-label use for weight loss or prediabetes is typically not covered. Need help navigating your insurance and prescription process? Klarity Health connects you with licensed providers who can evaluate your needs and guide you through the steps. Book your appointment today to get started.