Employer / Commercial Insurance
Covered with requirementsWhat you need to qualify
- A1C of 6.5% or higher
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
Type 2 Diabetes - Initial Approval
All of:
- Diagnosis of Type 2 diabetes as adjunct to diet and exercise to improve glycemic control
- Medication is NOT solely being used for weight loss
- Age consistent with FDA labeling
- Medical regimen includes standard of care for type 2 diabetes
- Does not have type 1 diabetes
- No severe gastrointestinal disease (gastroparesis)
- No personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2
- No concomitant use of more than one GLP-1 receptor agonist or in combination with a tirzepatide-containing product
- Failure, contraindication, or intolerance with THREE generic equivalents (if available) for at least three months each
Plus any one of:
- A1C >= 6.5%
- Fasting plasma glucose >= 126 mg/dL
- 2-hour plasma glucose >= 200 mg/dL during oral glucose tolerance test
- Random plasma glucose >= 200 mg/dL
Documentation to bring
- Completed prior authorization request form signed by prescribing provider
- Chart notes
- Lab results confirming T2DM diagnosis (A1C >= 6.5%, fasting plasma glucose >= 126 mg/dL, 2-hour PG >= 200 mg/dL during OGTT, or random plasma glucose >= 200 mg/dL)
- Documentation of failure, contraindication, or intolerance to three generic equivalent medications for at least three months each
- Supporting clinical documentation confirming standard of care for type 2 diabetes is in place
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- To renew, the plan looks for improvement in A1C and Decrease in A1C from baseline; adherence to prescribed therapy regimen for diabetes including diet and exercise.
Not covered when
- Severe gastrointestinal disease (gastroparesis)
- Personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2
- Concomitant use of more than one GLP-1 receptor agonist or in combination with a tirzepatide-containing product
- Medication used solely for weight loss (not covered under this indication)
- Type 1 diabetes
Policy note: Policy applies to Commercial and/or Marketplace plans only. Explicitly excludes Federal Employee Program, Medicare Advantage, Medicaid, and out-of-state BCBS plans. Brand-specific step therapy requires failure/contraindication/intolerance to THREE generic equivalents for at least 3 months each. At continuation, pancreatitis, severe hypersensitivity reaction, acute kidney injury, drug-induced immune mediated thrombocytopenia, and acute gallbladder disease are additional safety exclusions. Manufacturer samples and coupons not counted toward continuation eligibility. Member may be referred to case management for diabetes-related ancillary services.
Policy effective April 1, 2026 · verified June 2, 2026 · source: Download