Will Express Scripts Cover Ozempic? What You Need to Know About Insurance and Weight Loss Medications

If you’re taking Ozempic for weight loss or type 2 diabetes, you’re probably wondering: Will Express Scripts pay for Ozempic? The short answer is yes-but only under certain conditions. Express Scripts is one of the largest pharmacy benefit managers (PBMs) in the U.S., handling prescriptions for millions of people through employer plans, Medicare Part D, and other insurance networks. But coverage isn’t automatic. It depends on your plan, your diagnosis, and whether your doctor has jumped through the right hoops.

How Express Scripts Decides What to Cover

Express Scripts doesn’t set drug prices or decide coverage on its own. It follows the rules laid out by the insurance company or plan sponsor-like your employer, Medicare, or a private insurer. Ozempic (semaglutide) is approved by the FDA for two uses: treating type 2 diabetes and, since 2023, chronic weight management under the brand name Wegovy. But insurance plans often treat them differently.

Most plans cover Ozempic for diabetes without much trouble. It’s been on the market since 2017, and doctors have a clear clinical pathway for prescribing it. But for weight loss, coverage is much tighter. Many insurers still classify Ozempic as a "non-essential" or "lifestyle" drug when used for obesity, even though the American Medical Association and CDC recognize obesity as a chronic disease.

Express Scripts typically requires prior authorization for Ozempic when prescribed for weight loss. That means your doctor must submit documentation proving:

• You have a BMI of 30 or higher (or 27 with at least one weight-related condition like high blood pressure or sleep apnea)
• You’ve tried diet and exercise for at least 3-6 months
• You’re under ongoing medical supervision

Without this paperwork, your claim will be denied-even if you’re paying out of pocket at the pharmacy counter.

What Ozempic Costs Without Insurance

Without coverage, Ozempic can cost between $900 and $1,300 per month, depending on the dose and pharmacy. That’s why people turn to Express Scripts and other PBMs-they’re supposed to lower that price. But even with insurance, you might still pay hundreds per month.

Express Scripts negotiates discounts with manufacturers like Novo Nordisk. If your plan includes Ozempic in its formulary (the list of covered drugs), you might pay $25 to $100 per month after insurance. But if it’s not on the formulary-or if you’re on a high-deductible plan-you could pay full price until you hit your deductible.

Some people try to get Ozempic through mail-order pharmacies linked to Express Scripts. That’s often cheaper than picking it up at a local pharmacy, but only if your plan allows it. Always check your plan’s drug list before assuming coverage.

Why Some Plans Still Refuse to Cover Ozempic for Weight Loss

Even though the FDA approved Ozempic for weight loss in 2023, many insurance companies haven’t updated their policies. Why? Because they’re waiting for more long-term data on cost savings. They argue that while Ozempic helps people lose weight, it doesn’t yet prove it reduces hospital visits or lowers other medical costs over time.

Some plans also have strict step therapy rules. You might have to try cheaper weight loss drugs first-like phentermine or liraglutide (Saxenda)-before they’ll approve Ozempic. That’s frustrating, especially if those drugs didn’t work for you in the past.

Medicare Part D plans are especially inconsistent. Some cover Ozempic for weight loss; others don’t. The Inflation Reduction Act capped insulin at $35/month, but there’s no similar cap for weight loss drugs yet. That means millions of seniors on Medicare are paying full price unless their plan specifically includes it.

How to Check If Your Plan Covers Ozempic

Don’t guess. Don’t rely on what your friend heard. Go straight to the source.

1. Log in to your Express Scripts account at express-scripts.com
2. Use the Drug Search tool and type in "Ozempic"
3. Check the "Coverage Status"-it will say "Covered," "Not Covered," or "Requires Prior Authorization"
4. Look at your plan’s formulary document (usually under "Plan Documents")
5. Call the number on your insurance card and ask: "Is Ozempic covered for weight loss under my plan?" Ask for the rep’s name and reference number

If it says "requires prior authorization," ask your doctor’s office to start the process right away. It can take 5-10 business days. Don’t wait until your prescription runs out.

What to Do If Your Claim Is Denied

Denials happen. A lot. But you’re not stuck.

First, get the denial letter. It should explain why your claim was rejected. Common reasons: "not medically necessary," "off-label use," or "step therapy not completed."

Then, file an appeal. Express Scripts has a formal process:

• Submit a written appeal within 60 days of the denial
• Include a letter from your doctor explaining why Ozempic is medically necessary for you
• Attach lab results, BMI records, or proof of failed diet attempts
• Use the appeal form on the Express Scripts website or call customer service for help

If your appeal fails, you can request an external review by an independent third party. That’s your legal right under federal law.

Some patients have won appeals by showing that they have obesity-related conditions like fatty liver disease, PCOS, or hypertension-all of which are recognized as complications of excess weight.

Alternatives If Express Scripts Won’t Cover Ozempic

If you’re denied coverage and can’t afford the full price, here are your options:

• Novo Nordisk’s Savings Program: If you’re commercially insured, you might pay as little as $25 per month through Novo’s patient assistance program. Visit novonordisk-us.com and apply. You’ll need your prescription and insurance info.
• Mail-order pharmacies: Some online pharmacies offer Ozempic at lower prices than retail. Be careful-only use pharmacies that are licensed and verified by the National Association of Boards of Pharmacy (NABP). Look for the VIPPS seal.
• Generic semaglutide: As of 2025, the first generic version of semaglutide is expected to launch in the U.S. That could drop the price by 80% or more. Ask your doctor if you can switch to the generic when it becomes available.
• Medicare Advantage plans: Some Medicare Advantage plans include better drug coverage than standard Part D. If you’re eligible, consider switching during open enrollment.

Why This Matters Beyond Just the Cost

Ozempic isn’t just another weight loss pill. It’s a medication that changes how your body regulates hunger and blood sugar. For many people, it’s the first treatment that actually works after years of failed diets. When insurance denies it, it’s not just about money-it’s about access to care.

Studies show that people who take Ozempic for weight loss lose an average of 15% of their body weight in a year. That’s enough to reverse prediabetes, lower blood pressure, and reduce joint pain. But those benefits vanish if you can’t keep taking it.

Insurance coverage for weight loss medications is changing slowly. More employers and insurers are starting to cover them because they see the long-term savings in reduced diabetes, heart disease, and surgery costs. But until then, you’ll need to be your own advocate.

What’s Next for Ozempic and Insurance Coverage

As of 2025, more than 40 major U.S. insurers have updated their policies to cover weight loss medications like Ozempic. But coverage still varies widely. The federal government is under pressure to set national standards, especially after the Inflation Reduction Act’s success with insulin.

For now, the best strategy is to know your plan, work with your doctor, and keep records of every interaction. If you’re denied, don’t give up-appeals work. And if you’re paying full price, explore manufacturer savings programs. You’re not alone in this fight, and your health is worth pushing for.