What Is Ozempic and Its Uses?
Ozempic is a prescription drug with the active ingredient semaglutide. It’s FDA-approved to treat type 2 diabetes in adults, helping control blood sugar levels. It also reduces the risk of heart attack, stroke, or death in those with heart disease.
Some use Ozempic off-label for weight loss, but TRICARE’s coverage is limited. Understanding its approved uses is key to determining coverage eligibility.
TRICARE’s Pharmacy Benefit Overview
TRICARE provides comprehensive prescription drug coverage for military members, retirees, and their families. The program covers most FDA-approved medications, including Ozempic, under specific conditions. Coverage depends on your TRICARE plan, such as Prime, Select, or For Life.
Drugs are categorized into generic, brand-name, and non-formulary tiers. Ozempic is a brand-name drug, often requiring prior authorization.
Does TRICARE Cover Ozempic for Diabetes?
TRICARE covers Ozempic for type 2 diabetes if it’s medically necessary. You need a prescription from a licensed provider. A prior authorization and medical necessity form must be submitted to Express Scripts, TRICARE’s pharmacy benefit manager.
Without a type 2 diabetes diagnosis, TRICARE won’t cover Ozempic. Off-label use for weight loss is not approved.
Criteria for Ozempic Coverage
To get Ozempic covered, you must meet TRICARE’s requirements:
- Have a confirmed type 2 diabetes diagnosis.
- Be 18 or older.
- Provide medical records showing why Ozempic is needed.
- Have tried other diabetes medications, like metformin or Trulicity, unless contraindicated.
Your doctor must document these on the prior authorization form.
Prior Authorization Process for Ozempic
TRICARE requires prior authorization for Ozempic to ensure it’s appropriate. Your doctor submits a form to Express Scripts, detailing your medical history. This step confirms that Ozempic is the best treatment option.
Without approval, you’ll pay the full cost, which can be around $1,000 monthly. Electronic submissions via CoverMyMeds speed up the process.
How to Access the Prior Authorization Form
The prior authorization form is available online. Use the TRICARE Formulary Search Tool to find it by searching for Ozempic. Your doctor can also get it from Express Scripts or through CoverMyMeds.
Ensure your provider completes all sections to avoid delays. Missing information can lead to denials.
Steps to Submit the Prior Authorization Form
Submitting the form is straightforward but requires attention to detail. Follow these steps:
- Visit Your Doctor: Confirm Ozempic is necessary for your diabetes management.
- Complete the Form: Your provider fills out the medical necessity and prior authorization forms.
- Submit to Express Scripts: Send via mail, fax, or electronically through CoverMyMeds.
- Track Approval: Check the status online or call Express Scripts at 1-800-753-2851.
Mail forms to: Express Scripts, P.O. Box 52150, Phoenix, AZ 85072-9954.
What Information Is Needed on the Form?
The form requires specific details to justify Ozempic’s use. Your doctor must include:
- Your personal details (name, sponsor ID, date of birth).
- Proof of type 2 diabetes diagnosis.
- Records of prior diabetes treatments and their outcomes.
- A statement explaining why Ozempic is medically necessary.
Incomplete forms can delay or prevent approval, so review carefully.
Table: TRICARE Ozempic Coverage Requirements
| Requirement | Details |
|---|---|
| Diagnosis | Type 2 diabetes |
| Age | 18 or older |
| Prior Treatments | Tried other diabetes drugs (e.g., metformin, Trulicity) |
| Documentation | Medical necessity and prior authorization forms |
| Approval Process | Submit to Express Scripts via mail, fax, or ePA |
This table outlines the key criteria for Ozempic coverage.
Common Reasons for Denial and How to Avoid Them
Denials happen if TRICARE’s criteria aren’t met. Common issues include:
- No type 2 diabetes diagnosis.
- Missing records of prior medication attempts.
- Incomplete or incorrect form details.
Work with your doctor to ensure all documentation is accurate. Double-check forms before submission.
Appealing a Denied Request
If TRICARE denies your Ozempic request, you can appeal. Your doctor submits an appeal letter with additional evidence, like lab results or treatment history. Call Express Scripts at 1-800-753-2851 for guidance on the process.
Act quickly, as appeals have deadlines. Providing clear documentation improves your chances.
Costs and Copays for Ozempic
Once approved, Ozempic is covered under TRICARE’s pharmacy benefit. Active duty members pay nothing at military pharmacies or through home delivery. For others, the copay is $38 for a 90-day supply via TRICARE Home Delivery.
Retail pharmacies may have higher copays, around $60 for 30 days. Home delivery is the most cost-effective option.
Using TRICARE Home Delivery for Ozempic
TRICARE Home Delivery offers convenience and savings. After approval, your doctor sends the prescription to Express Scripts. You receive up to a 90-day supply at your doorstep.
Enroll by completing the New Patient Mail Order Form. Mail it with your prescription to Express Scripts.
Alternatives to Ozempic
If Ozempic isn’t covered or suitable, TRICARE covers other diabetes medications. Options include:
- Trulicity: May have a lower copay and similar benefits.
- Metformin: A first-line treatment for type 2 diabetes.
- Rybelsus: An oral form of semaglutide, also requiring prior authorization.
Discuss alternatives with your doctor if Ozempic is denied.
Off-Label Use for Weight Loss
Ozempic is not covered for weight loss, as it’s not FDA-approved for this purpose. TRICARE only covers Wegovy or Zepbound for weight management, with their own prior authorization requirements. If weight loss is your goal, ask your doctor about these alternatives.
Paying out-of-pocket for Ozempic is costly and not recommended. Always consult your provider.
Role of Your Healthcare Provider
Your doctor is critical in securing Ozempic coverage. They must document your diabetes diagnosis and treatment history. Encourage them to use electronic submission for faster processing.
If you face issues, your provider can contact Express Scripts for clarification. Their expertise ensures a smoother process.
How Long Does Approval Take?
Approval times depend on submission method. Electronic submissions via CoverMyMeds take a few days. Mailed or faxed forms may take one to two weeks.
Track your request online through Express Scripts. Follow up if you don’t hear back within a week.
Support for Managing Diabetes
Novo Nordisk, Ozempic’s manufacturer, offers resources for diabetes management. Their website provides tips on diet, exercise, and medication adherence. TRICARE also offers wellness programs to support your health.
Ask your doctor about these resources. They can complement your Ozempic treatment plan.
Staying Compliant with TRICARE Rules
Once approved, follow TRICARE’s guidelines. Continue your prescribed diabetes management plan, including diet and exercise. Regular check-ins with your doctor ensure ongoing coverage.
Failure to comply may result in coverage loss. Keep records of your progress.
Summary
Does TRICARE cover Ozempic? Yes, but only for type 2 diabetes with prior authorization. Your doctor must submit detailed forms to Express Scripts, proving medical necessity.
By meeting criteria and using tools like Home Delivery, you can access Ozempic affordably. Always work closely with your provider to avoid delays.
FAQ
Does TRICARE cover Ozempic for type 2 diabetes?
Yes, TRICARE covers Ozempic for type 2 diabetes if medically necessary. Your doctor must submit prior authorization and medical necessity forms. Approval requires a confirmed diagnosis and prior treatment attempts.
Can TRICARE cover Ozempic for weight loss?
No, TRICARE doesn’t cover Ozempic for weight loss, as it’s off-label. Wegovy or Zepbound are covered for weight management with prior authorization. Consult your doctor for alternatives.
How long does Ozempic prior authorization take?
Approval takes a few days for electronic submissions or up to two weeks for mailed forms. Track your request online. Contact Express Scripts for updates.
Where can I find the Ozempic prior authorization form?
Use the TRICARE Formulary Search Tool or get it from Express Scripts. Your doctor can access it via CoverMyMeds. Ensure all sections are complete.
What if my Ozempic request is denied?
You can appeal with additional medical evidence. Your doctor submits an appeal letter to Express Scripts. Act quickly to meet appeal deadlines.
How much does Ozempic cost with TRICARE?
Active duty members pay nothing. Others pay $38 for a 90-day supply via Home Delivery. Retail pharmacies may cost more, around $60 for 30 days.