Does New York Medicaid Cover Ozempic? NY Medicaid Guide 2026

New York residents covered by Medicaid asking about Ozempic coverage, it depends on several factors. NY Medicaid — overseen by the New York Medicaid agency — applies unique criteria for Ozempic (semaglutide) that differ from employer-sponsored coverage.

NY Medicaid’s Formulary Status for Ozempic

Federally, Medicaid programs are required to cover all FDA-approved medications from manufacturers participating in the Medicaid Drug Rebate Program. Novo Nordisk is enrolled in this program, which means NY Medicaid must cover Ozempic — though it may apply access restrictions.

What this means:

• Ozempic is included in NY Medicaid’s PDL with possible restrictions
• Prior authorization is mandatory across plan types
• Patient cost: $0–$3 for most Medicaid enrollees (cost-sharing caps apply)
• Managed care organizations (MCOs) in New York may have their own PA criteria beyond the state PDL

Coverage for Specific Indications

For type 2 diabetes:

• Coverage tends to be relatively standard with a diagnosis of type 2 diabetes
• Required documentation: prescriber attestation and clinical records
• The majority of managed care plans authorize Ozempic when PA criteria are met

For weight loss/obesity:

• NY Medicaid generally does not cover weight management prescriptions
• That said, CMS guidance have expanded options for states to cover weight management drugs as an optional benefit
• Check with NY Medicaid or your MCO for the latest formulary status

Steps to Get Ozempic Coverage Through NY Medicaid

1. Coordinate with your prescriber send a prior authorization — Include ICD-10 diagnosis codes, relevant lab results, and documentation of failed first-line therapies
2. Identify your MCO — New York Medicaid operates through managed care organizations, which may have unique requirements on top of the state PDL
3. Request a formulary exception if denied — CMS rules mandate an avenue for coverage exceptions when medically necessary
4. Request a state fair hearing — Medicaid enrollees have the right to an administrative appeal when coverage is denied for Ozempic

Key Points

• No cost-sharing barrier: For Medicaid beneficiaries, financial barriers are lower — the challenge is navigating PA
• Pharmacy access: The majority of New York pharmacy chains participate in the Medicaid network, though some plans require specialty pharmacy dispensing of Ozempic
• 90-day supply: Certain NY Medicaid MCOs permit mail-order dispensing helping minimize pharmacy visits