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