Medicaid
Covered with requirementsWhat you need to qualify
- Diagnosis documented with a code
Qualification pathways
You can qualify through any one of these.
Non-preferred GLP-1 agonist for T2DM with metformin use
All of:
- Diagnosis of type 2 diabetes mellitus
- Metformin claim in the last 186 days
Non-preferred GLP-1 agonist for T2DM with high A1C
All of:
- Diagnosis of type 2 diabetes mellitus
- HbA1c >= 9 in the last 186 days
Non-preferred GLP-1 agonist for T2DM with ASCVD
All of:
- Diagnosis of type 2 diabetes mellitus
- Diagnosis of ASCVD (e.g., CABG, Angina, CHD, CAD, MI, heart failure, CVD, TIA, PAD, aortic atherosclerosis, thoracic or abdominal aortic aneurysm)
Documentation to bring
- Documentation of type 2 diabetes mellitus diagnosis
- Metformin claim within the last 186 days OR HbA1c >= 9 within the last 186 days OR documentation of ASCVD diagnosis
Policy note: Ozempic is a non-preferred GLP-1 agonist on the Arkansas Medicaid formulary. The approval criteria listed apply to preferred GLP-1 agonists; non-preferred products 'will continue to require prior authorization.' The document does not specify separate non-preferred GLP-1 criteria distinct from the preferred criteria, so the preferred criteria are applied here as the applicable standard. PA requests submitted via CoverMyMeds or faxed to 800-424-7976.
Policy effective April 1, 2025 · verified June 4, 2026 · source: pacriteria