Applies to Employer and ACA Marketplace plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
Initial Approval: T2DM diagnosis confirmed + metformin trial or exception
All of:
- Diagnosis of type 2 diabetes mellitus confirmed by at least one of: A1C ≥ 6.5%, 2-hour plasma glucose ≥ 200 mg/dL during OGTT, symptoms of hyperglycemia with random plasma glucose ≥ 200 mg/dL, or FPG ≥ 126 mg/dL after fasting at least 8 hours
Plus any one of:
- Trial of at least 90-day supply of metformin within past 360 days under CVS Caremark prescription benefit with inadequate treatment response (documentation required)
- Intolerance or contraindication to metformin (documentation required)
- Member requires combination therapy AND has A1C ≥ 7.5% (documentation required)
Documentation to bring
- Medical record documenting T2DM diagnosis confirmed by at least one of: A1C ≥ 6.5%, 2-hour plasma glucose ≥ 200 mg/dL (OGTT), symptoms of hyperglycemia with random plasma glucose ≥ 200 mg/dL, or FPG ≥ 126 mg/dL after ≥ 8 hours fasting
- Documentation of inadequate response to at least 90-day metformin trial within past 360 days (if applicable pathway)
- Documentation of metformin intolerance or contraindication (if applicable pathway)
- Documentation of A1C ≥ 7.5% if requesting combination therapy pathway
- For continuation: documentation of A1C reduction since starting therapy
- For continuation: documentation that member has been on therapy at least 3 months (samples excluded)
Approval and renewal
- Renewal: every 12 months
- Renewal: Improvement in A1C.
- Renewal: Member must demonstrate a reduction in A1C since starting therapy. Member must also have been receiving the requested drug for at least 3 months (samples not counted). T2DM diagnosis confirmation is re-verified at continuation; however, the metformin trial and CV/CKD pathway requirements are not re-checked at renewal.
- Renewal: At least 12 weeks on therapy before the first renewal.
Policy note: If a claim is submitted with an approved ICD-10 code for type 2 diabetes mellitus under a CVS Caremark prescription benefit, the drug will be paid without requiring a PA. PA is only required if the appropriate ICD-10 code is absent. The document does not specify which ICD-10 codes are on the approved list. Mounjaro is listed in the policy header but has no special CV or CKD bypass pathways (those are only listed for Ozempic, Trulicity, and Victoza). Continuation approval duration is 1 year.
verified June 2, 2026 · source: C23650 D GLP-1 Receptor Agonist Bcbsar · View policy document (PDF)