Ozempic (semaglutide) is a widely used medication for managing type 2 diabetes, with some off-label use for weight loss. For New York State employees, retirees, and their families, a common concern is whether the Empire Plan covers Ozempic.
This article explores coverage details, eligibility, costs, and steps to access this medication under the Empire Plan.
What Is Ozempic?
Ozempic is a once-weekly injectable medication approved by the FDA for type 2 diabetes. It mimics the GLP-1 hormone to regulate blood sugar and reduce appetite. It’s not approved for type 1 diabetes or for children under 18.
Ozempic is also used off-label for weight loss, though Wegovy, with the same active ingredient, is FDA-approved for this purpose. Understanding its uses helps clarify coverage.
What Is the Empire Plan?
The Empire Plan is part of the New York State Health Insurance Program (NYSHIP), serving over 1.2 million public employees, retirees, and dependents. Administered by the Department of Civil Service, it offers comprehensive coverage, including hospital care, medical services, and prescriptions. UnitedHealthcare manages medical benefits, while CVS Caremark handles the prescription drug program.
The plan’s formulary lists covered medications, which is key to answering, “Does Empire Plan cover Ozempic?”
Does Empire Plan Cover Ozempic for Diabetes?
The Empire Plan covers Ozempic for type 2 diabetes when deemed medically necessary. A prescription from a licensed provider and prior authorization are required. Coverage is typically approved if other diabetes medications, like metformin, are ineffective or unsuitable.
Ozempic is listed on the Empire Plan’s formulary for diabetes management. Always verify coverage through NYSHIP’s resources.
Ozempic for Weight Loss: Empire Plan Coverage
Ozempic is not covered by the Empire Plan for weight loss, as it’s not FDA-approved for this purpose. Wegovy, approved for weight management, may be covered for obesity (BMI ≥30) or overweight (BMI ≥27) with conditions like hypertension. Prior authorization and step therapy are required for Wegovy.
Discuss weight loss options with your doctor. They can explore covered alternatives if Ozempic is not approved.
Prior Authorization Process
The Empire Plan requires prior authorization for Ozempic to confirm medical necessity. Your doctor must submit forms detailing your diabetes history, prior treatments, and current health status. This process ensures Ozempic is appropriate for your condition.
Incomplete forms can lead to coverage denials. Ensure your provider submits all required documentation promptly.
Step Therapy Requirements
Step therapy is often required for Ozempic under the Empire Plan. This means trying lower-cost diabetes medications, such as Trulicity or metformin, before Ozempic is approved. Your doctor must document why these alternatives didn’t work or aren’t suitable.
This requirement helps control costs. Work with your provider to meet step therapy criteria.
Costs of Ozempic with the Empire Plan
Ozempic’s cost under the Empire Plan depends on your pharmacy and coverage type. Copayments for brand-name drugs range from $30 to $70 for a 30-day supply. Mail-order through CVS Caremark may cost $80 for a 90-day supply, potentially lowering expenses.
Without coverage, Ozempic can cost $900 or more monthly. Novo Nordisk’s savings card may help, but Empire Plan beneficiaries are often ineligible.
Table: Empire Plan Copayments for Ozempic (2025)
| Pharmacy Type | Brand-Name (30 Days) | Mail-Order (90 Days) |
|---|---|---|
| Network Pharmacy | $30–$70 | N/A |
| CVS Caremark Mail-Order | $30–$70 | $80 |
| Non-Network Pharmacymeyi | Higher costs, coinsurance applies | N/A |
Note: Costs vary by plan and may change. Confirm with NYSHIP for current rates.
How to Access Ozempic Through the Empire Plan
To get Ozempic, consult your healthcare provider to confirm it’s suitable for your diabetes. They’ll submit a prescription and prior authorization forms to UnitedHealthcare or CVS Caremark. Use the Empire Plan’s formulary search tool to verify coverage.
Fill prescriptions at network pharmacies or through CVS Caremark mail-order. Complete documentation avoids delays.
Steps to Ensure Coverage Approval
Follow these steps to secure Ozempic coverage:
- Discuss your diabetes treatment history with your doctor.
- Request prior authorization and step therapy documentation.
- Use Empire Plan network pharmacies or mail-order services.
- Monitor approval status via NYSHIP’s website or by calling 1-877-769-7447.
Clear documentation is essential. Follow up with your provider or insurer if needed.
Appealing a Coverage Denial
If the Empire Plan denies Ozempic coverage, you can appeal. Review the denial letter to identify the reason, such as missing medical records. Your doctor can submit additional documentation, like lab results or prior treatment history.
Follow the appeal process outlined on NYSHIP’s website. Appeals typically take a few weeks to resolve.
Ozempic Side Effects and Monitoring
Ozempic may cause side effects like nausea, diarrhea, or low blood sugar. Serious risks include pancreatitis or thyroid tumors, though these are rare. Report severe symptoms, like persistent abdominal pain, to your doctor immediately.
The Empire Plan requires ongoing monitoring for continued coverage. Regular check-ups ensure safe use.
Off-Label Use and Empire Plan Policies
Using Ozempic off-label for weight loss is not covered by the Empire Plan. Wegovy is the preferred option for weight management, with strict criteria like BMI thresholds and prior authorization. Off-label use approvals are rare due to formulary restrictions.
Discuss alternatives with your doctor. They can recommend covered weight loss treatments.
Combining Empire Plan with Medicare
For retirees with Medicare, the Empire Plan coordinates as secondary coverage. Medicare Part D may cover Ozempic for diabetes, with the Empire Plan covering remaining costs. Prior authorization is still required.
Check with Medicare and NYSHIP for coordination details. This ensures seamless coverage.
Long-Term Use of Ozempic
Ozempic is often a long-term treatment for type 2 diabetes. The Empire Plan covers ongoing use if medical necessity is documented. Regular doctor visits and updated authorizations are required to maintain coverage.
Monitor for side effects and effectiveness. Your provider will adjust treatment as needed.
Lifestyle Changes to Support Ozempic
Ozempic works best with a healthy diet and regular exercise. The Empire Plan may cover nutrition counseling or diabetes management programs to support treatment. These programs improve blood sugar control and enhance Ozempic’s effectiveness.
Ask your doctor about covered resources. Lifestyle changes boost treatment outcomes.
Using Network Providers for Ozempic
The Empire Plan encourages using network providers to reduce costs. Network pharmacies charge only copayments, while non-network pharmacies involve higher coinsurance. Use the Empire Plan Provider Directory to find participating pharmacies.
This minimizes out-of-pocket expenses. Always verify provider status before filling prescriptions.
Ozempic for Dependents and Retirees
The Empire Plan covers Ozempic for dependents and retirees if criteria are met. The process is the same as for active employees, requiring prior authorization and step therapy. Medicare coordination applies for retirees over 65.
Confirm eligibility with NYSHIP. Coverage ensures access for all eligible beneficiaries.
Why Empire Plan Covers Ozempic
The Empire Plan covers Ozempic for type 2 diabetes because it’s FDA-approved and effective. Coverage aligns with NYSHIP’s goal of providing evidence-based care. Strict criteria, like prior authorization, balance cost and medical necessity.
This ensures appropriate use for enrollees. Always verify coverage details.
What to Discuss with Your Doctor
Before starting Ozempic, share your diabetes history, prior treatments, and any side effects with your doctor. Ask about the Empire Plan’s prior authorization process and monitoring requirements. Discuss how to manage potential side effects.
Clear communication with your provider ensures smooth coverage approval. It also supports safe use.
Summary
The Empire Plan covers Ozempic for type 2 diabetes when medically necessary, requiring prior authorization and often step therapy. Copayments range from $30 to $80, depending on the pharmacy. Coverage for weight loss is unlikely, but Wegovy may be an option. Consult your doctor, use network pharmacies, and appeal denials to access Ozempic affordably.
FAQ Section
Does Empire Plan cover Ozempic for type 2 diabetes?
Yes, the Empire Plan covers Ozempic for type 2 diabetes if medically necessary. Prior authorization and step therapy are required. Check the formulary for details.
Does Empire Plan cover Ozempic for weight loss?
No, Ozempic is not covered for weight loss, as it’s not FDA-approved for this. Wegovy may be covered for obesity with strict criteria. Discuss options with your doctor.
What are the costs of Ozempic with the Empire Plan?
Copayments range from $30–$70 for a 30-day supply or $80 for 90 days via mail-order. Costs vary by pharmacy. Confirm with NYSHIP for current rates.
What if the Empire Plan denies Ozempic coverage?
Appeal by submitting additional medical records through your doctor. Follow NYSHIP’s appeal process. Secondary insurance or savings programs may help.
Are there side effects of Ozempic to consider?
Common side effects include nausea and diarrhea; serious risks like pancreatitis are rare. Report severe symptoms to your doctor. Regular monitoring is required.