Aetna · Kidney Disease (CKD)

Aetna coverage for Ozempic (Kidney Disease (CKD))

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

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