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