Express Scripts is a big company that helps millions of people with their prescription drug coverage, including those with employer, Medicare, or individual plans. They decide if medicines like Ozempic (semaglutide) are covered.
So, does Express Scripts cover Ozempic? Yes, they generally cover it if you have type 2 diabetes (which is its approved use). However, if you’re using it for weight loss (which isn’t its primary approved purpose), coverage is often limited or not available. You might also need special approval and have to meet certain conditions. Since Ozempic can cost over $1,000 a month without coverage, it’s vital to understand Express Scripts’ policies.
In today’s article, we will explain their approach, updates for 2025, requirements, alternatives, and simple steps, based on official guides and user feedback.
Overview of Ozempic and Express Scripts’ Role
Ozempic is a GLP-1 receptor agonist from Novo Nordisk, made to help adults with type 2 diabetes manage their blood sugar when combined with diet and exercise.
It also helps with weight loss, which is why some doctors prescribe it for obesity, even though Wegovy is the version approved for that purpose. Express Scripts, part of Evernorth (owned by Cigna), handles benefits for over 100 million people and decides what to cover based on medical proof, cost, and insurance plans.
In 2025, Express Scripts plans (like their main ones) will still cover Ozempic for diabetes. It’ll usually be on a “Tier 2” or “Tier 3” list, which means you’ll pay a copay. However, if you want Ozempic for weight loss, they usually won’t cover it unless you have other health problems that make it medically necessary.
Express Scripts’ General Coverage Policy for Ozempic
Express Scripts covers Ozempic for type 2 diabetes in most plans, classifying it as a specialty drug requiring prior authorization (PA) to confirm medical necessity. This includes documented diagnosis, inadequate response to first-line therapies like metformin, and ongoing monitoring. Copays vary: $25-$100 for preferred tiers in commercial plans, potentially lower in Medicare PDPs.
For weight loss, getting coverage is much harder. Most plans won’t pay if obesity is the only problem, often requiring you to try other treatments first. Exceptions are rare and strict, usually only for severe obesity (BMI over 40) with other serious health issues. Express Scripts does this to control costs, as demand for these drugs is high.
2025 Updates and Changes in Coverage
In 2025, Express Scripts is making some changes to help people afford certain weight-loss drugs. Through its Patient Assurance Program, some members will pay no more than $25 a month for these medications. This update, happening in July 2025, is meant to make drugs like Ozempic and Rybelsus more accessible for both diabetes and weight loss, especially since they’ve been hard to get.
Ozempic is now on the main approved drug list. But some plans won’t cover it for weight loss if you don’t have diabetes. Medicare will still cover it for diabetes if you get approval. Other insurance plans made it harder to get coverage for weight loss because too many people were asking for it.
Prior Authorization and Requirements
PA is mandatory for Ozempic in most Express Scripts plans to verify necessity. Requirements include:
- Type 2 diabetes diagnosis (A1C >7% or equivalent).
- Trial of cheaper alternatives (e.g., metformin, sulfonylureas).
- No contraindications (e.g., thyroid cancer history).
- For weight loss (if covered): BMI ≥30 or ≥27 with conditions, plus lifestyle program participation.
Appeals for denials need medical documentation.
User Experiences and Reports
People on Reddit share different stories about getting their Ozempic covered.
Some have good news, like one person who said, “Express Scripts approved my Ozempic for diabetes after getting prior authorization. My copay is only $25.”
Others have bad news, like someone who was denied and said, “They wouldn’t cover it for weight loss because my plan doesn’t include it.”
Many people like getting their medication delivered to their homes but complain that the approval process takes a long time.
Alternatives If Not Covered
If you’re not approved for Ozempic, your insurance might cover other weight loss medicines like Wegovy or Zepbound, but you’ll probably need prior authorization (PA) for them.
You can also get a savings card from Novo Nordisk to pay as little as $25 a month. Another option is compounded semaglutide, which is cheaper, but insurance won’t pay for it. Some insurance plans might also pay you back for joining lifestyle programs.
How to Check Your Specific Plan
To find out if Ozempic or similar medicines are covered by your insurance, start by checking your plan’s list of covered drugs, called a formulary. This list shows which medicines are covered and how much you might need to pay. You can usually find it on your insurance company’s website or by calling their customer service.
Challenges and Appeals Process
Your insurance might say no if the medicine is prescribed for a use not officially approved, or if the “prior approval” paperwork isn’t filled out completely. If they deny it, you can fight the decision by sending in more information. You usually have 60 days to do this. If they still say no, you can ask for a higher-level review. Keep in mind that new rules about costs starting in 2025 mean insurance companies are looking at claims even more closely.
Conclusion
In 2025, Express Scripts will cover Ozempic for diabetes if you get prior approval (PA). They also offer a Patient Assistance Program (PAP) to help with costs. However, coverage for weight loss is limited. It’s a good idea to check your specific plan’s details. If your request is denied, look into other options.
FAQs
Does Express Scripts cover Ozempic for type 2 diabetes?
Yes, Express Scripts usually covers Ozempic for type 2 diabetes in 2025 plans, but prior approval is needed. Copays depend on your plan, and some eligible members may pay as little as $25/month. Check your plan for details.
Why might Express Scripts deny Ozempic for weight loss?
Express Scripts often limits Ozempic for weight loss since it’s not FDA-approved for that, and many plans don’t cover obesity. It may be covered for serious cases with other health issues, but approval is tough.
What are the 2025 changes to Express Scripts’ Ozempic coverage?
In 2025, Express Scripts made the Patient Assurance Program better by adding GLP-1 medications for weight loss. These medications now cost only $25/month for plans that cover them. Some plans, like Basic and Medicare PDPs, still need prior approval. A new home delivery service for injectable medications started in May to make access easier.
How do I get prior authorization for Ozempic with Express Scripts?
Your doctor needs to send a prior authorization (PA) request for you. They should include your diagnosis, a list of other medications you’ve tried, and why Ozempic is medically necessary. Your doctor can find the forms on express-scripts.com. Approval usually takes 1-3 days. If your request is denied, you can appeal within 60 days by providing more information.
What alternatives does Express Scripts cover if Ozempic is denied?
If Ozempic isn’t covered, there are other options. For weight loss, some plans might cover Wegovy or Zepbound, especially if your BMI is 30 or higher, but you’ll need approval. For diabetes, Trulicity or Victoza might be covered.
Trusted Resources
- Express Scripts Medicare 2025 Formulary – https://www.express-scripts.com/pdf/egwp/F0PA3P5A_508.pdf
- 2025 Express Scripts National Preferred Formulary – https://www.express-scripts.com/pdf/formulary/NPE1702_204612.pdf
- Evernorth: Express Scripts Expands Patient Assurance Program – https://www.evernorth.com/articles/express-scripts-expands-patient-assurance-program-drive-affordability-and-access-glp-1s
- 2025 Express Scripts National Preferred Formulary – https://www.afspa.org/wp-content/uploads/2025/02/National-Preferred-Alpha-with-Exclusion-List.250103.pdf
- 2025 Express Scripts National Preferred Formulary Exclusions – https://www.express-scripts.com/pdf/formulary/NPF_Preferred_Formulary_Exclusions2025.pdf
- Express Scripts Medicare 2025 Formulary – https://www.pehp.org/mango/pdf/pehp/pdc/f0hp4c2a_508c_FE6EB789.pdf
