Employer / Commercial Insurance
Covered with requirementsWhat you need to qualify
- A1C of 6.5% or higher
- Diagnosis documented with a code
- Trial of metformin for at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication", "ASCVD", "CKD", "combination_therapy_with_high_A1C"])
- Lab results confirming eligibility
Qualification 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
- To renew, the plan looks for improvement in A1C, 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, and 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.pdf