Is Ozempic a Tier 4 Drug? Understanding Its Insurance Classification

October 10, 2025 •

4 min read

According to data from Medicare, Ozempic is typically placed on Tier 3 of prescription drug formularies, classifying it as a non-preferred brand-name medication rather than a Tier 4 drug. Its specific tier and cost are subject to variation depending on your individual health insurance plan and the medical condition for which it is prescribed.

Quick Summary

Ozempic is generally classified as a Tier 3, or sometimes Tier 2, brand-name medication, which means higher costs than generics, not the highest-cost Tier 4 status. Its insurance coverage and price are dependent on your specific plan's formulary, diagnosis, and adherence to requirements like prior authorization.

Key Points

Ozempic is Not a Tier 4 Drug: It is most commonly classified as a Tier 3 (non-preferred brand) or Tier 2 (preferred brand) medication on insurance formularies.
Cost Depends on Your Plan: The specific tier and out-of-pocket cost for Ozempic are determined by your individual health insurance plan's formulary.
Prior Authorization is Usually Required: Due to its cost, most insurers require your doctor to obtain prior authorization to prove medical necessity for Ozempic.
Diagnosis is a Key Factor: Coverage is most likely for the FDA-approved use in type 2 diabetes; off-label use for weight loss is typically not covered by insurance.
Savings Options are Available: Manufacturer savings programs, patient assistance programs, and prescription discount cards can help reduce the high cost of Ozempic for eligible individuals.

Understanding the Drug Tier System

Prescription drug tiers are a common method used by insurance companies to determine the out-of-pocket cost for medications. These tiers categorize drugs based on factors such as cost, availability, and brand status. Generally, the lower the tier number, the lower your co-payment, with higher tiers reserved for specialty or non-preferred brand-name medications. A typical drug formulary includes a hierarchy of tiers:

Tier 1: Generics. These are the most affordable drugs, often with the lowest co-payment. They contain the same active ingredients as their brand-name counterparts.
Tier 2: Preferred Brand. This tier includes brand-name drugs that the insurer has negotiated a discount for. They are more expensive than generics but less costly than non-preferred brands.
Tier 3: Non-Preferred Brand. This tier includes higher-cost, non-preferred brand-name medications. This is where Ozempic is most commonly found on Medicare formularies and many commercial plans. These drugs come with higher co-payments or coinsurance.
Tier 4/Specialty Tier. This is reserved for the most expensive specialty medications, such as injectables or high-cost therapies. This tier typically has the highest patient out-of-pocket costs.

Is Ozempic a Tier 4 Drug? The Definitive Answer

Based on various insurance formularies, Ozempic is typically not a Tier 4 drug. Most commonly, it is categorized as a Tier 3 medication. For example, Medicare Part D plans and many major commercial insurers, such as United Healthcare (UHC), often place Ozempic in Tier 3 when prescribed for its FDA-approved use of treating type 2 diabetes. Some UHC plans may even list it as a Tier 2 medication under certain conditions, leading to a potentially lower co-payment for the patient. However, the exact placement can vary significantly from one plan to another, making it crucial for individuals to check their specific plan's formulary.

Factors Influencing Ozempic's Coverage and Cost

The placement of Ozempic within a drug tier is not the only factor determining your final out-of-pocket cost. Several requirements and conditions, including prior authorization and diagnosis, also play a significant role.

The Critical Role of Prior Authorization

Due to its high cost, most insurance plans require a prior authorization (PA) for Ozempic coverage. This is a process where your doctor must submit documentation to your insurance company proving that the medication is medically necessary for your specific condition. This step is designed to ensure the medication is being used according to the insurer’s guidelines and for its FDA-approved purpose.

The Importance of Your Medical Diagnosis

The reason for which you are prescribed Ozempic is a critical factor in determining insurance coverage. Ozempic is FDA-approved to treat type 2 diabetes. It is also used off-label for weight loss, but insurance providers are unlikely to cover it for weight loss alone. For individuals needing a GLP-1 for weight management, the FDA-approved alternative, Wegovy (which contains the same active ingredient, semaglutide), may be covered by certain plans, but it also carries its own set of coverage rules and requirements.

Navigating "Step Therapy" Requirements

Some insurance plans implement a policy called step therapy. This means you must first try and fail a less expensive or preferred medication for your condition before the insurer will cover a more costly one like Ozempic. This is particularly common for diabetes management, where insurers may require you to try metformin or other first-line drugs before approving Ozempic.

Comparison of Drug Tier Classifications and Costs


Feature	Tier 1: Generic	Tier 2: Preferred Brand	Tier 3: Non-Preferred Brand	Tier 4/Specialty
Typical Cost	Lowest	Moderate	Higher	Highest
Example Drugs	Metformin, Lisinopril	Certain common brands	Ozempic, Mounjaro	High-cost injectables
Ozempic's Tier	N/A	Possible (on some plans)	Most Common	Rare/Depends on plan
Insurance Requirements	Often none	May require PA	Often requires PA & step therapy	Usually requires PA & specialty pharmacy
Impact on Patient	Minimal out-of-pocket cost	Moderate co-payment	Higher co-payment or coinsurance	Highest co-payment or coinsurance

What to Do If Coverage is Denied

If your prior authorization request for Ozempic is denied, or if your plan simply doesn't cover it, you are not out of options. Here's a breakdown of the steps you can take:

Appealing a Prior Authorization Denial: If your request is denied, you have the right to appeal. Your healthcare provider's office can assist with this process, which often involves submitting more detailed information or a formal appeal letter.
Exploring Alternatives and Patient Programs: You can look into alternatives like Wegovy if your diagnosis is for weight loss. For help with Ozempic costs, the manufacturer, Novo Nordisk, offers a savings card for eligible patients with commercial insurance, which could lower the cost to as little as $25 for a three-month supply. They also have a patient assistance program for those who are uninsured or underinsured.
Prescription Discount Cards: Services like GoodRx and SingleCare can provide coupons that significantly reduce the retail price of Ozempic, though this may not apply if you are using a government-assisted program.

Conclusion

While Ozempic is not typically a Tier 4 drug, it is generally classified as a non-preferred brand (Tier 3) on most insurance formularies, which means it is a higher-cost medication than generics and some preferred brands. Patients can expect to face significant out-of-pocket costs, prior authorization requirements, and potentially step therapy depending on their specific insurance plan and diagnosis. To manage these costs, it is essential to check your plan's formulary, work closely with your healthcare provider to meet all prior authorization criteria, and explore manufacturer savings programs or prescription discount cards.

For more detailed information on specific Ozempic coverage, always consult your insurance provider directly or check your plan's official formulary.

Frequently Asked Questions

While Ozempic is a high-cost medication, it is typically categorized as a Tier 3 non-preferred brand rather than a specialty drug (often Tier 4) on many formularies. However, some plans may classify it differently, so it's important to check your specific plan details.

Yes, most Medicare Part D prescription drug plans cover Ozempic when it is prescribed for its FDA-approved use of treating type 2 diabetes. However, it is almost always placed on a higher tier, like Tier 3, and may require prior authorization.

Prior authorization is required by many insurance plans because Ozempic is an expensive, brand-name medication. This process helps the insurer confirm that the medication is medically necessary for your condition and is being used appropriately.

Insurance is unlikely to cover Ozempic solely for weight loss, as this is an off-label use. For weight management, the FDA-approved version of semaglutide, Wegovy, may be covered by some plans, but check your specific formulary for details.

You can check your insurance plan's official drug list, known as a formulary, which is often available on the insurer's website. You can also call the member services number on your insurance ID card to ask directly.

Yes, the manufacturer, Novo Nordisk, offers a savings card for commercially insured patients that can help reduce out-of-pocket costs. They also have a patient assistance program for uninsured or underinsured individuals who meet certain criteria.

If your coverage is denied, you have the right to appeal the decision with the help of your healthcare provider. You can also explore manufacturer savings programs, discount cards, or discuss FDA-approved alternatives with your doctor.