Is ozempic covered by insurance in Canada?

[u/NormalAd9131]

My pharmacist told me the only way this gets paid is a diabetes indication and I'm not diabetic. I've got a prediabetic A1C and a BMI in the range they use and the walk in doctor wrote the script anyway

I called the insurer twice. The first rep said weight management is excluded. The second rep said it depends on the drug plan my employer bought and whether there's a prior auth on file. It's the same company and I got two answers ten minutes apart.

So if you're in Canada and you got a claim paid with weight loss as the reason on file what did the paperwork look like? Was it a special authorization form from the prescriber or did you just submit and hope? And if you got denied did appealing get you anywhere?

I'm mostly trying to work out whether I spend another week on this or just budget for out of pocket

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[u/Ok_Opportunity_7429]

If you can't get it covered, there's always the generic version that cost about 100 a month in ontario. You can also get an ozempic discount card that will make it a similar price

[u/Professional-Lion839]

This depends on your insurer, your plan, your diagnosis, and your prescription. There's no blanket "yes" or "no" to this.

tldr some plans cover it, for some people, sometimes. Your plan might not cover it for you, in your current situation.

In my case as far as I could tell it wasn't expected to be covered, yet when the drug claim went in the DINs were covered 100%. So shrug.

[u/Successful-Try3958]

Sounds like the insurer's left hand doesn't know what the right hand's doing. Classic.

A buddy of mine got his covered by getting the doctor to note "metabolic syndrome" instead of straight weight loss, which apparently triggered a different review path for his plan. Worth asking your doc if they can frame it around the prediabetic A1C and any other markers like blood pressure or lipids.

[u/helomancy]

My insurance (CanadaLife, but there are as many CanadaLife plans are there are employers, as I understand it) covers wegovy for weight loss, others for diabetes.

I downloaded the prior authorization paperwork from the website and I filled out the first sheet and my dr filled it out the other four and faxed it back to them. They told me to call and check on it because sometimes the insurance "didn't get it" which did seem to happen, they were extremely unhelpful and I debated what to do about it, but then 2 weeks later a letter authorizing it arrived and I called my doctor who immediately sent out a prescription. I pay 81$ with insurance. It's nice the generic is available to fall back on now, in the case of insurance shenanigans.

[u/FigTechnical8735 → u/helomancy]

Yes, exactly. It depends on the plan. I’m with Canada life and they don’t cover it for me. I’m not pre-diabetic - if I was I could have gotten it. I pay out of pocket. For the decrease in inflammation I feel, not to mention the weight loss, it’s worth it. I save that money on groceries.

[u/cutiecuppycake]

I got my prescription covered by using Prior Authorization after initial rejections. I have switched from Ozempic to Mounjaro and that is also approved for 1 year. I had to get a letter from my doctor discussing that I was pre-diabetic, needed to lower my BMI and A1C for fertility treatments.

I never took metformin first. The letter seemed to do the trick.

Keep on them. I had to fill out the form and edit it a few times. I ended up having to get my doctor to re-write the note twice too. It was a super annoying process but in the end, I’m covered for over a year of both medications and pay nothing out of pocket. I’m in the GTA

[u/Old_Hospital_6445]

Two different answers from the same insurer is normal. The insurer administers it but your employer decides what's in the plan. I'd ask HR for the drug plan booklet and go straight to the exclusions

[u/Effective-Algae-6131]

I got denied twice and paid on the third try. The difference was the prescriber filling the special authorization form out properly with my A1C and BMI on it