Aetna

Does Aetna cover Ozempic?

Quick answer · Type 2 Diabetes

Aetna covers Ozempic for type 2 diabetes with prior authorization on Employer / Commercial Insurance and ACA Marketplace.

  • Employer / Commercial Insurance: Covered with requirements. A1C of 6.5% or higher
  • ACA Marketplace: Covered with requirements. A1C of 6.5% or higher

Last verified June 2, 2026. Policy effective March 18, 2026. Source: policy-259.html. How we verify this data →

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Ozempic for Type 2 Diabetes

What Aetna requires, by plan type. Open this indication on its own page →

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

  • Age 18 and older
  • A1C of 6.5% or higher
  • Trial of metformin for at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication", "inadequate_response", "MASLD", "MASH", "established_CVD", "CKD"])
  • Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Initial approval — T2DM with lab confirmation and metformin step therapy or exception

All of:

  • Patient has NOT been receiving a stable maintenance dose of a GLP-1 or GIP/GLP-1 agonist for at least 3 months
  • Documentation of T2DM diagnosis via one of: A1C >= 6.5%, 2-hour PG >= 200 mg/dL on OGTT, random PG >= 200 mg/dL with hyperglycemic symptoms, or fasting PG >= 126 mg/dL (fasted >= 8 hours)

Plus any one of:

  • Inadequate treatment response, intolerance, or contraindication to metformin
  • Requires combination therapy AND A1C >= 7.5%
  • Diagnosis of MASLD or MASH
  • Established cardiovascular disease (Ozempic injection)
  • Diagnosis of chronic kidney disease (Ozempic injection)

Continuation — T2DM with demonstrated benefit or qualifying comorbidity

All of:

  • Patient HAS been receiving a stable maintenance dose of a GLP-1 or GIP/GLP-1 agonist for at least 3 months
  • Documentation of T2DM diagnosis via one of: A1C >= 6.5%, 2-hour PG >= 200 mg/dL on OGTT, random PG >= 200 mg/dL with hyperglycemic symptoms, or fasting PG >= 126 mg/dL (fasted >= 8 hours)

Plus any one of:

  • Demonstrated reduction in A1C since starting GLP-1/GIP-GLP-1 therapy
  • Diagnosis of MASLD or MASH
  • Established cardiovascular disease (Ozempic injection)
  • Diagnosis of chronic kidney disease (Ozempic injection)

Documentation to bring

  • Documentation of T2DM diagnosis (A1C lab result >= 6.5%, OR 2-hour plasma glucose >= 200 mg/dL on OGTT, OR random plasma glucose >= 200 mg/dL with hyperglycemia symptoms, OR fasting plasma glucose >= 126 mg/dL with documentation of >= 8-hour fast)
  • Documentation that patient has NOT been on stable GLP-1 or GIP/GLP-1 agonist dose for at least 3 months (initial only)
  • Documentation of metformin inadequate response, intolerance, or contraindication; OR A1C >= 7.5% requiring combination therapy; OR qualifying comorbidity (MASLD/MASH, established CVD, or CKD)

Quantity limits

  • 2mg/3mL — 1 prefilled pen (3 mL) / 21 days; 3 prefilled pens (9 mL) / 63 days (84-day)
  • 4mg/3mL — 1 prefilled pen (3 mL) / 21 days; 3 prefilled pens (9 mL) / 63 days (84-day)
  • 8mg/3mL — 1 prefilled pen (3 mL) / 21 days; 3 prefilled pens (9 mL) / 63 days (84-day)
  • 9mg tablet (1.5mg, 4mg, 9mg tablet strengths) — 30 tablets / 25 days; 90 tablets / 75 days (84-day)

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • To renew, the plan looks for improvement in A1C and Patient must demonstrate A1C reduction since starting therapy, OR have a diagnosis of MASLD/MASH, OR have established CVD, OR have CKD. At continuation, the requirement that the patient NOT be on a stable GLP-1 dose is reversed — patient must now BE on a stable dose for at least 3 months.

Policy note: The quantity limit table for Ozempic tablets (9 mg once daily — 1.5 mg, 4 mg, 9 mg strengths in bottles of 30 tablets) appears in the document as Ozempic tablets, but the document otherwise refers to tablet formulations under 'Rybelsus and Ozempic Tablets.' The PA criteria are shared across all GLP-1/GIP-GLP-1 drugs in this policy. For initial approval, the patient must NOT already be on a stable GLP-1 dose; for continuation, they MUST be on one. Metformin step therapy is required unless an exception applies. The CKD exception to metformin step therapy applies specifically to Ozempic injection.

Policy effective March 18, 2026 · verified June 2, 2026 · source: policy-259.html

ACA Marketplace

Covered with requirements

What you need to qualify

  • Age 18 and older
  • A1C of 6.5% or higher
  • Trial of metformin for at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication", "inadequate_response", "MASLD", "MASH", "established_CVD", "CKD"])
  • Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Initial approval — T2DM with lab confirmation and metformin step therapy or exception

All of:

  • Patient has NOT been receiving a stable maintenance dose of a GLP-1 or GIP/GLP-1 agonist for at least 3 months
  • Documentation of T2DM diagnosis via one of: A1C >= 6.5%, 2-hour PG >= 200 mg/dL on OGTT, random PG >= 200 mg/dL with hyperglycemic symptoms, or fasting PG >= 126 mg/dL (fasted >= 8 hours)

Plus any one of:

  • Inadequate treatment response, intolerance, or contraindication to metformin
  • Requires combination therapy AND A1C >= 7.5%
  • Diagnosis of MASLD or MASH
  • Established cardiovascular disease (Ozempic injection)
  • Diagnosis of chronic kidney disease (Ozempic injection)

Continuation — T2DM with demonstrated benefit or qualifying comorbidity

All of:

  • Patient HAS been receiving a stable maintenance dose of a GLP-1 or GIP/GLP-1 agonist for at least 3 months
  • Documentation of T2DM diagnosis via one of: A1C >= 6.5%, 2-hour PG >= 200 mg/dL on OGTT, random PG >= 200 mg/dL with hyperglycemic symptoms, or fasting PG >= 126 mg/dL (fasted >= 8 hours)

Plus any one of:

  • Demonstrated reduction in A1C since starting GLP-1/GIP-GLP-1 therapy
  • Diagnosis of MASLD or MASH
  • Established cardiovascular disease (Ozempic injection)
  • Diagnosis of chronic kidney disease (Ozempic injection)

Documentation to bring

  • Documentation of T2DM diagnosis (A1C lab result >= 6.5%, OR 2-hour plasma glucose >= 200 mg/dL on OGTT, OR random plasma glucose >= 200 mg/dL with hyperglycemia symptoms, OR fasting plasma glucose >= 126 mg/dL with documentation of >= 8-hour fast)
  • Documentation that patient has NOT been on stable GLP-1 or GIP/GLP-1 agonist dose for at least 3 months (initial only)
  • Documentation of metformin inadequate response, intolerance, or contraindication; OR A1C >= 7.5% requiring combination therapy; OR qualifying comorbidity (MASLD/MASH, established CVD, or CKD)

Quantity limits

  • 2mg/3mL — 1 prefilled pen (3 mL) / 21 days; 3 prefilled pens (9 mL) / 63 days (84-day)
  • 4mg/3mL — 1 prefilled pen (3 mL) / 21 days; 3 prefilled pens (9 mL) / 63 days (84-day)
  • 8mg/3mL — 1 prefilled pen (3 mL) / 21 days; 3 prefilled pens (9 mL) / 63 days (84-day)
  • 9mg tablet (1.5mg, 4mg, 9mg tablet strengths) — 30 tablets / 25 days; 90 tablets / 75 days (84-day)

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • To renew, the plan looks for improvement in A1C and Patient must demonstrate A1C reduction since starting therapy, OR have a diagnosis of MASLD/MASH, OR have established CVD, OR have CKD. At continuation, the requirement that the patient NOT be on a stable GLP-1 dose is reversed — patient must now BE on a stable dose for at least 3 months.

Policy note: The quantity limit table for Ozempic tablets (9 mg once daily — 1.5 mg, 4 mg, 9 mg strengths in bottles of 30 tablets) appears in the document as Ozempic tablets, but the document otherwise refers to tablet formulations under 'Rybelsus and Ozempic Tablets.' The PA criteria are shared across all GLP-1/GIP-GLP-1 drugs in this policy. For initial approval, the patient must NOT already be on a stable GLP-1 dose; for continuation, they MUST be on one. Metformin step therapy is required unless an exception applies. The CKD exception to metformin step therapy applies specifically to Ozempic injection.

Policy effective March 18, 2026 · verified June 2, 2026 · source: policy-259.html

Ozempic for Heart Disease Risk Reduction

What Aetna requires, by plan type. Open this indication on its own page →

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

  • Age 18 and older
  • A1C of 6.5% or higher
  • Trial of metformin for at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication", "inadequate_response", "MASLD", "MASH", "established_CVD", "CKD"])
  • Established cardiovascular disease (established_cardiovascular_disease)
  • Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Initial approval — CV risk reduction for T2DM with established CVD

All of:

  • Patient has NOT been receiving a stable maintenance dose of a GLP-1 or GIP/GLP-1 agonist for at least 3 months
  • Documentation of T2DM diagnosis via one of: A1C >= 6.5%, 2-hour PG >= 200 mg/dL on OGTT, random PG >= 200 mg/dL with hyperglycemic symptoms, or fasting PG >= 126 mg/dL (fasted >= 8 hours)
  • Established cardiovascular disease

Plus any one of:

  • Inadequate treatment response, intolerance, or contraindication to metformin
  • Requires combination therapy AND A1C >= 7.5%
  • Diagnosis of MASLD or MASH
  • Established cardiovascular disease (satisfies both the CV indication requirement and the metformin exception)

Continuation — CV risk reduction with demonstrated benefit or qualifying comorbidity

All of:

  • Patient HAS been receiving a stable maintenance dose of a GLP-1 or GIP/GLP-1 agonist for at least 3 months
  • Documentation of T2DM diagnosis confirmed
  • Established cardiovascular disease

Plus any one of:

  • Demonstrated reduction in A1C since starting therapy
  • Diagnosis of MASLD or MASH
  • Established cardiovascular disease

Documentation to bring

  • Documentation of T2DM diagnosis (A1C >= 6.5%, OR 2-hour PG >= 200 mg/dL on OGTT, OR random PG >= 200 mg/dL with hyperglycemia symptoms, OR fasting PG >= 126 mg/dL with documented >= 8-hour fast)
  • Documentation of established cardiovascular disease
  • Documentation that patient has NOT been on stable GLP-1 or GIP/GLP-1 agonist for at least 3 months (initial only)
  • Documentation of metformin inadequate response, intolerance, or contraindication; OR A1C >= 7.5% requiring combination therapy; OR qualifying comorbidity

Quantity limits

  • 2mg/3mL — 1 prefilled pen (3 mL) / 21 days; 3 prefilled pens (9 mL) / 63 days (84-day)
  • 4mg/3mL — 1 prefilled pen (3 mL) / 21 days; 3 prefilled pens (9 mL) / 63 days (84-day)
  • 8mg/3mL — 1 prefilled pen (3 mL) / 21 days; 3 prefilled pens (9 mL) / 63 days (84-day)

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • To renew, the plan looks for improvement in A1C and Patient must demonstrate A1C reduction since starting therapy, OR have a diagnosis of MASLD/MASH, OR have established CVD. The requirement that the patient NOT be on a stable GLP-1 dose flips to MUST be on stable dose for at least 3 months at continuation.

Policy note: CV risk reduction for Ozempic injection is covered as part of the T2DM criteria — the established CVD diagnosis serves as the qualifying exception to metformin step therapy. This policy does not separate CV risk reduction as an independent standalone indication; it is handled within the T2DM authorization framework. The patient must still have T2DM and meet the diagnosis confirmation criteria.

Policy effective March 18, 2026 · verified June 2, 2026 · source: policy-259.html

ACA Marketplace

Covered with requirements

What you need to qualify

  • Age 18 and older
  • A1C of 6.5% or higher
  • Trial of metformin for at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication", "inadequate_response", "MASLD", "MASH", "established_CVD", "CKD"])
  • Established cardiovascular disease (established_cardiovascular_disease)
  • Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Initial approval — CV risk reduction for T2DM with established CVD

All of:

  • Patient has NOT been receiving a stable maintenance dose of a GLP-1 or GIP/GLP-1 agonist for at least 3 months
  • Documentation of T2DM diagnosis via one of: A1C >= 6.5%, 2-hour PG >= 200 mg/dL on OGTT, random PG >= 200 mg/dL with hyperglycemic symptoms, or fasting PG >= 126 mg/dL (fasted >= 8 hours)
  • Established cardiovascular disease

Plus any one of:

  • Inadequate treatment response, intolerance, or contraindication to metformin
  • Requires combination therapy AND A1C >= 7.5%
  • Diagnosis of MASLD or MASH
  • Established cardiovascular disease (satisfies both the CV indication requirement and the metformin exception)

Continuation — CV risk reduction with demonstrated benefit or qualifying comorbidity

All of:

  • Patient HAS been receiving a stable maintenance dose of a GLP-1 or GIP/GLP-1 agonist for at least 3 months
  • Documentation of T2DM diagnosis confirmed
  • Established cardiovascular disease

Plus any one of:

  • Demonstrated reduction in A1C since starting therapy
  • Diagnosis of MASLD or MASH
  • Established cardiovascular disease

Documentation to bring

  • Documentation of T2DM diagnosis (A1C >= 6.5%, OR 2-hour PG >= 200 mg/dL on OGTT, OR random PG >= 200 mg/dL with hyperglycemia symptoms, OR fasting PG >= 126 mg/dL with documented >= 8-hour fast)
  • Documentation of established cardiovascular disease
  • Documentation that patient has NOT been on stable GLP-1 or GIP/GLP-1 agonist for at least 3 months (initial only)
  • Documentation of metformin inadequate response, intolerance, or contraindication; OR A1C >= 7.5% requiring combination therapy; OR qualifying comorbidity

Quantity limits

  • 2mg/3mL — 1 prefilled pen (3 mL) / 21 days; 3 prefilled pens (9 mL) / 63 days (84-day)
  • 4mg/3mL — 1 prefilled pen (3 mL) / 21 days; 3 prefilled pens (9 mL) / 63 days (84-day)
  • 8mg/3mL — 1 prefilled pen (3 mL) / 21 days; 3 prefilled pens (9 mL) / 63 days (84-day)

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • To renew, the plan looks for improvement in A1C and Patient must demonstrate A1C reduction since starting therapy, OR have a diagnosis of MASLD/MASH, OR have established CVD. The requirement that the patient NOT be on a stable GLP-1 dose flips to MUST be on stable dose for at least 3 months at continuation.

Policy note: CV risk reduction for Ozempic injection is covered as part of the T2DM criteria — the established CVD diagnosis serves as the qualifying exception to metformin step therapy. This policy does not separate CV risk reduction as an independent standalone indication; it is handled within the T2DM authorization framework. The patient must still have T2DM and meet the diagnosis confirmation criteria.

Policy effective March 18, 2026 · verified June 2, 2026 · source: policy-259.html

Ozempic for Kidney Disease (CKD)

What Aetna requires, by plan type. Open this indication on its own page →

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

  • Age 18 and older
  • A1C of 6.5% or higher
  • Trial of metformin for at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication", "inadequate_response", "MASLD", "MASH", "CKD"])
  • Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Initial approval — CKD in T2DM (Ozempic injection only)

All of:

  • Patient has NOT been receiving a stable maintenance dose of a GLP-1 or GIP/GLP-1 agonist for at least 3 months
  • Documentation of T2DM diagnosis via one of: A1C >= 6.5%, 2-hour PG >= 200 mg/dL on OGTT, random PG >= 200 mg/dL with hyperglycemic symptoms, or fasting PG >= 126 mg/dL (fasted >= 8 hours)
  • Diagnosis of chronic kidney disease

Plus any one of:

  • Inadequate treatment response, intolerance, or contraindication to metformin
  • Requires combination therapy AND A1C >= 7.5%
  • Diagnosis of MASLD or MASH
  • Diagnosis of CKD (satisfies both the CKD indication and metformin exception)

Continuation — CKD in T2DM (Ozempic injection only)

All of:

  • Patient HAS been receiving a stable maintenance dose of a GLP-1 or GIP/GLP-1 agonist for at least 3 months
  • Documentation of T2DM diagnosis confirmed
  • Diagnosis of chronic kidney disease

Plus any one of:

  • Demonstrated reduction in A1C since starting therapy
  • Diagnosis of MASLD or MASH
  • Diagnosis of CKD

Documentation to bring

  • Documentation of T2DM diagnosis (A1C >= 6.5%, OR 2-hour PG >= 200 mg/dL on OGTT, OR random PG >= 200 mg/dL with hyperglycemia symptoms, OR fasting PG >= 126 mg/dL with documented >= 8-hour fast)
  • Documentation of CKD diagnosis
  • Documentation that patient has NOT been on stable GLP-1 or GIP/GLP-1 agonist for at least 3 months (initial only)
  • Documentation of metformin inadequate response, intolerance, or contraindication; OR A1C >= 7.5% requiring combination therapy; OR CKD as qualifying exception

Quantity limits

  • 2mg/3mL — 1 prefilled pen (3 mL) / 21 days; 3 prefilled pens (9 mL) / 63 days (84-day)
  • 4mg/3mL — 1 prefilled pen (3 mL) / 21 days; 3 prefilled pens (9 mL) / 63 days (84-day)
  • 8mg/3mL — 1 prefilled pen (3 mL) / 21 days; 3 prefilled pens (9 mL) / 63 days (84-day)

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • To renew, the plan looks for improvement in A1C and Patient must demonstrate A1C reduction since starting therapy, OR have a diagnosis of MASLD/MASH, OR have CKD diagnosis (for Ozempic injection). The stable-dose requirement flips at continuation.

Policy note: The policy states CKD as a qualifying exception to metformin step therapy specifically for Ozempic injection. No eGFR or UACR thresholds are specified for Ozempic CKD coverage (unlike Trulicity/Victoza which require eGFR < 30). The CKD criteria are handled within the T2DM authorization framework.

Policy effective March 18, 2026 · verified June 2, 2026 · source: policy-259.html

ACA Marketplace

Covered with requirements

What you need to qualify

  • Age 18 and older
  • A1C of 6.5% or higher
  • Trial of metformin for at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication", "inadequate_response", "MASLD", "MASH", "CKD"])
  • Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Initial approval — CKD in T2DM (Ozempic injection only)

All of:

  • Patient has NOT been receiving a stable maintenance dose of a GLP-1 or GIP/GLP-1 agonist for at least 3 months
  • Documentation of T2DM diagnosis via one of: A1C >= 6.5%, 2-hour PG >= 200 mg/dL on OGTT, random PG >= 200 mg/dL with hyperglycemic symptoms, or fasting PG >= 126 mg/dL (fasted >= 8 hours)
  • Diagnosis of chronic kidney disease

Plus any one of:

  • Inadequate treatment response, intolerance, or contraindication to metformin
  • Requires combination therapy AND A1C >= 7.5%
  • Diagnosis of MASLD or MASH
  • Diagnosis of CKD (satisfies both the CKD indication and metformin exception)

Continuation — CKD in T2DM (Ozempic injection only)

All of:

  • Patient HAS been receiving a stable maintenance dose of a GLP-1 or GIP/GLP-1 agonist for at least 3 months
  • Documentation of T2DM diagnosis confirmed
  • Diagnosis of chronic kidney disease

Plus any one of:

  • Demonstrated reduction in A1C since starting therapy
  • Diagnosis of MASLD or MASH
  • Diagnosis of CKD

Documentation to bring

  • Documentation of T2DM diagnosis (A1C >= 6.5%, OR 2-hour PG >= 200 mg/dL on OGTT, OR random PG >= 200 mg/dL with hyperglycemia symptoms, OR fasting PG >= 126 mg/dL with documented >= 8-hour fast)
  • Documentation of CKD diagnosis
  • Documentation that patient has NOT been on stable GLP-1 or GIP/GLP-1 agonist for at least 3 months (initial only)
  • Documentation of metformin inadequate response, intolerance, or contraindication; OR A1C >= 7.5% requiring combination therapy; OR CKD as qualifying exception

Quantity limits

  • 2mg/3mL — 1 prefilled pen (3 mL) / 21 days; 3 prefilled pens (9 mL) / 63 days (84-day)
  • 4mg/3mL — 1 prefilled pen (3 mL) / 21 days; 3 prefilled pens (9 mL) / 63 days (84-day)
  • 8mg/3mL — 1 prefilled pen (3 mL) / 21 days; 3 prefilled pens (9 mL) / 63 days (84-day)

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • To renew, the plan looks for improvement in A1C and Patient must demonstrate A1C reduction since starting therapy, OR have a diagnosis of MASLD/MASH, OR have CKD diagnosis (for Ozempic injection). The stable-dose requirement flips at continuation.

Policy note: The policy states CKD as a qualifying exception to metformin step therapy specifically for Ozempic injection. No eGFR or UACR thresholds are specified for Ozempic CKD coverage (unlike Trulicity/Victoza which require eGFR < 30). The CKD criteria are handled within the T2DM authorization framework.

Policy effective March 18, 2026 · verified June 2, 2026 · source: policy-259.html

Why Ozempic requests get denied by Aetna

Based on what this policy asks for. Fix these before the first submission.

  1. Wrong brand for the diagnosis. Ozempic and Wegovy are the same molecule with different approved uses; a request for Ozempic under a diagnosis that matches Wegovy is routinely denied.
  2. No recent A1C result on file.
  3. No documented metformin trial (dose, dates, and outcome) or a stated reason it can't be used.

Frequently asked questions

Does Aetna cover Ozempic?
Aetna covers Ozempic for type 2 diabetes with prior authorization on Employer / Commercial Insurance and ACA Marketplace.
Do you have to try metformin before Ozempic?
Yes for type 2 diabetes: Aetna requires a documented trial of metformin of at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication", "inadequate_response", "MASLD", "MASH", "established_CVD", "CKD"]).
How long does a Ozempic approval last with Aetna?
Initial approvals last 12 months, and renewals are granted in 12-month periods.
What does Aetna require to renew Ozempic?
Improvement in A1C and Patient must demonstrate A1C reduction since starting therapy, OR have a diagnosis of MASLD/MASH, OR have established CVD, OR have CKD. At continuation, the requirement that the patient NOT be on a stable GLP-1 dose is reversed — patient must now BE on a stable dose for at least 3 months.
How current is this information?
This page reflects Aetna's written policy as of March 18, 2026, last verified against the source document on June 2, 2026.

Other medications under Aetna

Ozempic coverage under other plans

All insurance plans · All medications

This page summarizes Aetna's written prior-authorization policy. It is not a guarantee of coverage; plans vary by employer and benefit design. Verify with your plan before relying on it.