Applies to Employer and ACA Marketplace plans.
Covered with requirementsQualification 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
- Renewal: Improvement in A1C.
- Renewal: 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