Employer / Commercial Insurance
Covered (preferred drug)What you need to qualify
- A1C of 6.5% or higher
- Established cardiovascular disease (MI, stroke, revascularization, TIA, unstable_angina, amputation, and CAD)
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
CV risk reduction with T2DM
All of:
- Diagnosis of type 2 diabetes
- A1C >= 6.5% confirmed by lab test or medical records
- Requested agent will be used to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal MI, or non-fatal stroke)
- 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
- Patient age is within FDA labeling OR there is support for use outside labeled age range
Plus any one of:
- Patient has established cardiovascular disease (e.g., MI, stroke, any revascularization procedure, TIA, unstable angina, amputation, symptomatic or asymptomatic CAD)
- Patient has multiple cardiovascular risk factors (e.g., hypertension, dyslipidemia, family history of CVD, smoking)
Documentation to bring
- Documentation of type 2 diabetes diagnosis
- Lab test results or medical records confirming A1C >= 6.5%
- Documentation of established CVD (e.g., MI, stroke, revascularization, TIA, unstable angina, amputation, CAD) OR multiple CV risk factors (HTN, dyslipidemia, family history CVD, smoking)
- Confirmation that requested agent will be used to reduce CV event risk
- Confirmation that patient will not use with DPP-4 containing agent
- Confirmation that patient will not use with another GLP-1 receptor agonist
Quantity limits
- 2 MG/3ML, 4 MG/3ML, 8 MG/3ML — 1 pen per 28 days
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- To renew, the plan looks for Continuation requires prior preferred agent use within 90 days or prescriber attestation of risk if discontinued.
Not covered when
- Combination with DPP-4 containing agents not permitted
- Combination with another GLP-1 receptor agonist not permitted
- FDA labeled contraindications to the requested agent
- Personal or family history of MTC or MEN 2
- Prior serious hypersensitivity reaction to semaglutide or product components
Policy note: The CV risk reduction pathway under this policy requires T2DM diagnosis AND A1C >= 6.5% — this is a diabetes-managed policy, not a standalone CV indication. The policy does not exclude patients with diabetes; rather diabetes is required. The policy covers CV risk reduction as a qualifying pathway within the diabetes PA criteria. Ozempic tablets are also covered for CV risk reduction per FDA labeling and listed in the policy agent summary.
Policy effective May 11, 2026 · verified June 2, 2026 · source: KS_GLP1_ProgSum.pdf