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)
- Established cardiovascular disease (documentation required)
- Member requires combination therapy AND has A1C ≥ 7.5% (documentation required)
- Diagnosis of chronic kidney disease (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 established cardiovascular disease (if applicable pathway)
- Documentation of chronic kidney disease diagnosis (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, CV disease, and CKD bypass pathway requirements are not re-checked at renewal.
- Renewal: At least 12 weeks on therapy before the first renewal.
Policy note: Ozempic has a specific bypass pathway for established cardiovascular disease (skipping metformin trial) and a separate bypass for chronic kidney disease diagnosis. If a claim is submitted with an approved ICD-10 code for T2DM under CVS Caremark, no PA is required. Continuation approval is for 1 year.
verified June 2, 2026 · source: C23650 D GLP-1 Receptor Agonist Bcbsar · View policy document (PDF)