Medicaid
Covered with requirementsWhat you need to qualify
- Diagnosis documented with a code
Qualification pathways
You can qualify through any one of these.
Standard approval: failure of preferred antidiabetic agents
All of:
- Appropriate diagnosis supported by documentation in the patient record
- FDA-approved indication
- Failed 30-day treatment trials with at least two prescribed and preferred antidiabetic agents (generic, OTC, or brand) within the past 12 months
Allergy or contraindication to all preferred agents
All of:
- Appropriate diagnosis supported by documentation in the patient record
- FDA-approved indication
- Documented allergy or contraindication to all preferred agents in this class
Stable therapy
All of:
- Documented stable therapy on the requested medication for 60 consecutive days or greater
Documentation to bring
- Documentation of appropriate diagnosis in patient record
- Documentation of failed 30-day trials with at least two preferred antidiabetic agents within the past 12 months, OR documented allergy/contraindication to all preferred agents
- Medical justification (peer-reviewed literature, medical record documentation, or other requested information)
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- To renew, the plan looks for Approval may be given for those with documented stable therapy on the requested medication for 60 consecutive days or greater.
Policy note: Preferred agents in the Incretin Mimetic class are 'preferred with clinical criteria' and must meet specified clinical criteria including FDA-approved indications and prior therapy trials. Medical justification may include peer-reviewed literature, medical record documentation, or other specifically requested information. Antidiabetic agents are included in the electronic PA program. PA requests meeting prior usage requirements may be accepted verbally.
Policy effective August 15, 2025 · verified June 3, 2026 · source: Pa policy