Employer / Commercial Insurance
Covered (preferred drug)What you need to qualify
- Age 10 and older
- A1C of 6.5% or higher
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
Initial approval for T2DM
All of:
- Diagnosis of type 2 diabetes mellitus
- Patient is 10 years of age or older
Plus any one of:
- HbA1c >= 6.5% (from accredited laboratory; point-of-care testing not acceptable)
- Fasting plasma glucose (FPG) >= 126 mg/dL (from accredited laboratory; point-of-care testing not acceptable)
- 2-hour plasma glucose (2-h PG) >= 200 mg/dL (from accredited laboratory; point-of-care testing not acceptable)
Documentation to bring
- Documentation confirming diagnosis of type 2 diabetes mellitus
- Lab result from accredited laboratory (not point-of-care) showing HbA1c >= 6.5%, FPG >= 126 mg/dL, or 2-h PG >= 200 mg/dL
- Documentation that patient is 10 years of age or older
Not covered when
- Use in patients younger than 10 years of age is considered investigational
- Use for any non-FDA approved indication is considered investigational
Policy note: Mounjaro is listed as a preferred product. Laboratory testing must be performed by an accredited laboratory; point-of-care testing is not acceptable for confirming diagnosis. Wegovy (semaglutide) is addressed separately in medical policy 00886 and is not covered by this policy. This policy focuses on GLP-1/GIP agonists for diabetes only.
Policy effective May 1, 2026 · verified June 2, 2026 · source: GLP1AgonistsforDiabetes.pdf