Employer / Commercial Insurance
Covered with requirementsWhat 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