Ozempic vs Wegovy vs Mounjaro vs Zepbound: Insurance Coverage Comparison
Quick Answer
For diabetes: Ozempic (72% coverage) and Mounjaro (68% coverage) have best approval rates.
For weight loss: All drugs face high denial rates (24-31% coverage), but state mandates and strong appeals can overcome barriers.
Cost without insurance: $935-$1,349/month. With insurance: $25-$100/month copay.
The 4 GLP-1 Drugs: What's the Difference?
| Drug | Active Ingredient | FDA Approval | Typical Dose | Avg Cost/Month |
|---|---|---|---|---|
| Ozempic | Semaglutide | Type 2 Diabetes | 0.25-2.0mg weekly | $935 |
| Wegovy | Semaglutide | Obesity/Weight Loss | 2.4mg weekly | $1,349 |
| Mounjaro | Tirzepatide | Type 2 Diabetes | 2.5-15mg weekly | $1,023 |
| Zepbound | Tirzepatide | Obesity/Weight Loss | 2.5-15mg weekly | $1,059 |
Key Insight: Same Drugs, Different FDA Approvals
- Ozempic = Wegovy: Both are semaglutide. Wegovy is just higher dose with weight loss indication.
- Mounjaro = Zepbound: Both are tirzepatide. Zepbound is branded for obesity.
Insurance Coverage Rates by Condition
For Type 2 Diabetes
- Ozempic: 72% coverage rate (highest)
- Mounjaro: 68% coverage rate
- Both face step therapy: 80-85% of plans require trying metformin first
Why diabetes coverage is better: Insurers view diabetes as serious medical condition. FDA approval for A1C reduction makes it "medically necessary" rather than "cosmetic."
For Weight Loss/Obesity
- Wegovy: 28% coverage rate (highest for weight loss)
- Ozempic (off-label): 31% coverage for weight loss (technically not approved)
- Zepbound: 24% coverage rate (newer, fewer plans cover yet)
- Mounjaro (off-label): ~20% coverage for weight loss
The coverage gap: Federal law allows insurers to exclude weight loss drugs. Only 28 states mandate obesity treatment coverage.
Step Therapy Requirements by Drug
Ozempic (Diabetes)
Typical step therapy:
- Metformin 3-6 months (first-line)
- Sulfonylureas OR DPP-4 inhibitors 3-6 months (second-line)
- Then GLP-1 drugs like Ozempic
Override strategies:
- Document prior metformin trials (even from years ago)
- Emphasize GI intolerance to metformin (very common)
- Cite cardiovascular benefits of GLP-1s in high-risk patients
- Urgent appeal if A1C >9% or complications present
Wegovy (Weight Loss)
Typical requirements:
- BMI ≥35 OR BMI ≥30 with comorbidity (hypertension, diabetes, sleep apnea)
- 6-12 months documented weight loss program (diet/exercise) failure
- Some plans require trying Contrave, Qsymia, or phentermine first
Override strategies:
- Emphasize FDA approval for obesity (not cosmetic)
- Document medical complications (prediabetes, NAFLD, joint pain)
- State mandate citations (CA, IL, NY require coverage)
- Cardiovascular risk reduction data from SELECT trial
Mounjaro vs Zepbound
Mounjaro (diabetes): Similar step therapy to Ozempic. Slightly harder to get as second-line because it's newer/more expensive.
Zepbound (weight loss): Hardest to get approved (24% coverage) because:
- Newest drug (approved November 2023)
- Many plans haven't added to formulary yet
- Higher cost than Wegovy
- Requires same weight loss program documentation as Wegovy
Pro tip: If you need weight loss AND have prediabetes (A1C 5.7-6.4%), request Mounjaro instead of Zepbound. Better coverage because it's diabetes-approved.
Which Drug Should You Request?
If You Have Type 2 Diabetes
First choice: Ozempic
- Highest coverage rate (72%)
- Extensive clinical data (insurers trust it)
- Manufacturer savings card available
Alternative: Mounjaro
- Better A1C reduction in trials (average 2.0-2.5% drop vs 1.5-2.0% with Ozempic)
- More weight loss (15-21% vs 10-15%)
- Good option if Ozempic plateaus or doesn't reach A1C goal
If You Need Weight Loss (No Diabetes)
First choice: Wegovy
- FDA-approved specifically for obesity
- Highest coverage rate for weight loss (28%)
- Strong clinical trial data (STEP trials)
Alternative strategy: Get diagnosed with prediabetes
- Check A1C - if 5.7-6.4%, you have prediabetes
- Request Ozempic or Mounjaro as diabetes prevention
- 72% coverage vs 28% (much better approval odds)
If You Have Prediabetes + Need Weight Loss
Best strategy: Ozempic or Mounjaro
- Frame as diabetes prevention, not weight loss
- Cite ADA guidelines: intensive lifestyle intervention OR medication for prediabetes + high risk
- Weight loss becomes "therapeutic benefit" rather than primary indication
- Much better coverage odds (72% vs 28%)
Cost Comparison: With vs Without Insurance
Monthly Costs
| Drug | Cash Price | With Insurance (Copay) | Savings Card Price |
|---|---|---|---|
| Ozempic | $935 | $25-$75 | $25 (with commercial insurance) |
| Wegovy | $1,349 | $50-$100 | $25 (with commercial insurance) |
| Mounjaro | $1,023 | $25-$75 | $25 (with commercial insurance) |
| Zepbound | $1,059 | $50-$100 | $25-$150 (with commercial insurance) |
Annual Savings If You Win Appeal
- Ozempic: $10,920/year (vs $300-$900 with coverage) = $10,020-$10,620 saved
- Wegovy: $16,188/year (vs $600-$1,200 with coverage) = $14,988-$15,588 saved
- Mounjaro: $12,276/year (vs $300-$900 with coverage) = $11,376-$11,976 saved
- Zepbound: $12,708/year (vs $600-$1,200 with coverage) = $11,508-$12,108 saved
Manufacturer Savings Programs
Ozempic/Wegovy Savings Card (Novo Nordisk)
Eligibility:
- Must have commercial insurance (even if drug is denied)
- NOT valid with Medicare, Medicaid, or if uninsured
- Income limits may apply
Savings: Reduces copay to as low as $25/month
Apply: novocare.com/semaglutide/savings-card.html
Mounjaro/Zepbound Savings Card (Eli Lilly)
Eligibility:
- Commercial insurance required (denial okay)
- NOT valid with government insurance
Savings: $25/month for Mounjaro, $25-$150/month for Zepbound
Apply: mounjaro.com/savings-resources or zepbound.lilly.com/savings
Important: Savings Cards as Bridge Strategy
Manufacturer cards are NOT a substitute for insurance coverage. They:
- Expire after 12 months (must reapply)
- Don't count toward deductible or out-of-pocket max
- Can be discontinued anytime by manufacturer
Best use: Use savings card while appealing denial. Once coverage approved, you'll have permanent $25-$100 copay.
State-Specific Coverage Mandates
States Requiring GLP-1 Coverage
California: Must cover FDA-approved obesity treatments for BMI ≥30 or BMI ≥27 with comorbidity
Illinois: Comprehensive Anti-Obesity Medication Access Act (2024) requires coverage
New York: Diabetes medication coverage required; some plans must cover obesity drugs
Massachusetts: Diabetes care mandate includes GLP-1 coverage
Check your state's full coverage laws →
Which Drug Has Easiest Approval?
Ranking by Approval Difficulty
- Easiest: Ozempic for diabetes (72% coverage, established drug)
- Second: Mounjaro for diabetes (68% coverage, newer but strong data)
- Third: Wegovy for obesity (28% coverage, but FDA-approved indication)
- Hardest: Zepbound for obesity (24% coverage, newest, fewer plans cover)
Strategic Switching
If denied Wegovy: Get A1C tested. If ≥5.7% (prediabetes), switch request to Ozempic for "diabetes prevention." Much better coverage.
If denied Zepbound: Same strategy - check for prediabetes and request Mounjaro instead.
If Ozempic plateaus: After 6+ months, if weight loss stalls or A1C doesn't reach goal, request Mounjaro switch citing superior clinical trial results.
Bottom Line: Which Should You Choose?
Decision Framework
You have Type 2 Diabetes:
- Start with Ozempic (72% coverage, easiest approval)
- If denied or plateau, try Mounjaro (better A1C/weight loss data)
You need weight loss only:
- Get A1C tested first - if ≥5.7%, request Ozempic/Mounjaro as diabetes prevention (72% coverage vs 28%)
- If A1C normal, request Wegovy with strong medical necessity letter
- Emphasize comorbidities: hypertension, sleep apnea, NAFLD, joint disease
You're in CA, IL, NY, MA:
- Cite state mandate requiring obesity treatment coverage
- Higher success rate even for weight loss-only indication
Ready to Appeal Your Denial?
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