Does SilverScript Cover Ozempic? Medicare Advantage Coverage Guide 2026
If you’re enrolled in on SilverScript Part D (from CVS Health/Aetna) often ask whether SilverScript covers Ozempic (semaglutide). The short answer is: coverage is determined by your plan’s formulary tier, Part D structure, and medical indication.
SilverScript’s Formulary Position on Ozempic
SilverScript Part D uses a drug formulary that tiers medications based on coverage level. As of 2026, Ozempic is usually placed on Tier 4 (Non-preferred specialty) across SilverScript plan designs.
Cost implications:
- Out-of-pocket cost: significant cost-sharing varying by coverage phase
- Prior authorization: Yes — clinical documentation must be provided
- Quantity limits: May apply — standard 30-day supply limits
- Step therapy: May require trying metformin, insulin, or other treatments first
The Medicare Part D coverage gap (donut hole), you’ll owe 25% coinsurance before catastrophic coverage applies.
Coverage for Different Indications
For type 2 diabetes (FDA-approved):
- SilverScript typically will authorize Ozempic with appropriate documentation
- PA criteria: HbA1c levels, prior medication history
- Success is more likely with proper documentation
For weight loss (for chronic weight management):
- CMS policy generally prohibits anti-obesity medications from formulary coverage
- An exception exists: recent CMS guidance expanded Part D coverage eligibility for certain anti-obesity drugs
- SilverScript might include enhanced coverage that cover weight management medications — check your Evidence of Coverage document
What You’ll Pay With SilverScript
Estimating your real cost for Ozempic on SilverScript requires knowing where you are in the benefit structure.
| Coverage Phase | Typical Cost |
|---|---|
| Initial Deductible ($590 in 2026) | You pay everything: $850–$1,200/month |
| Initial Coverage | 25-33% coinsurance |
| Coverage Gap (Donut Hole) | Significant coinsurance |
| Catastrophic Coverage | $0 or small copay |
Starting in 2025, total OOP costs won’t exceed $2,000 — providing substantial relief to patients on expensive specialty drugs.
How to Maximize Coverage
- Ask for a tier exception — If Ozempic is non-preferred, the prescriber can submit a tier reduction or formulary exception with clinical justification
- Apply for patient assistance — Novo Nordisk offers copay cards that may help with Part D costs (note: savings cards typically don’t work with government plans)
- Shop during AEP — Open enrollment (Oct 15–Dec 7) allows find a better-tier placement
- Explore LIS — For qualifying individuals can get reduced Part D costs that significantly reduce out-of-pocket expenses