Applies to Employer and ACA Marketplace plans.
Covered (preferred drug)Qualification pathways
You can qualify through any one of these.
Initial approval - preferred agent
All of:
- Diagnosis of type 2 diabetes
- A1C ≥ 6.5% confirmed by lab test (lab results or medical records required)
- Requested agent is a preferred agent
- Patient age within FDA labeling for the requested indication, or support for off-label age use
- Patient will NOT use requested agent in combination with a DPP-4 containing agent
- Patient will NOT use requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications to the requested agent
Continuation of therapy
All of:
- Diagnosis of type 2 diabetes
- A1C ≥ 6.5% confirmed by lab test (lab results or medical records required)
- Patient will NOT use requested agent in combination with a DPP-4 containing agent
- Patient will NOT use requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications to the requested agent
Plus any one of:
- Patient has been treated with a preferred agent within the past 90 days (not starting on samples)
- Prescriber states patient has been treated with a preferred agent within the past 90 days (not starting on samples) AND patient is at risk if therapy with a preferred agent is discontinued
Documentation to bring
- Documentation of type 2 diabetes diagnosis
- Lab results confirming A1C ≥ 6.5% (or medical records)
- For continuation: documentation of prior preferred agent use within past 90 days, or prescriber attestation with clinical risk justification
- Documentation that patient will not use requested agent with a DPP-4 inhibitor
- Documentation that patient will not use requested agent with another GLP-1 receptor agonist
Quantity limits
- 2 MG/3ML, 4 MG/3ML, 8 MG/3ML — 1 pen
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
Not covered when
- Combination use with DPP-4 containing agents (e.g., Januvia, Janumet, Tradjenta, Onglyza, Nesina, Alogliptin/metformin, Alogliptin/pioglitazone, Brynovin, Janumet XR, Jentadueto, Jentadueto XR, Kombiglyze XR, Trijardy, Zituvio, Zituvimet, Zituvimet XR)
- Combination use with another GLP-1 receptor agonist (e.g., Saxenda, Wegovy, Zepbound, Bydureon, Byetta, Exenatide, Mounjaro, Rybelsus, Trulicity, Victoza)
- FDA labeled contraindications to the requested agent (including personal/family history of MTC or MEN 2, prior serious hypersensitivity to active ingredient or components)
Policy note: Ozempic is listed as a preferred agent on this formulary. The policy covers Ozempic for type 2 diabetes. It also has FDA indications for CV risk reduction and CKD, but the PA clinical criteria in this document are written solely around type 2 diabetes diagnosis and do not differentiate by sub-indication (CV risk reduction, CKD). Step therapy exemption may apply if a prior health plan paid for the medication — documentation of a paid claim may be required.
Policy effective February 1, 2026 · verified June 2, 2026 · source: Albp GLP-1 Agonists Paql Prog Sum