Applies to Employer and ACA Marketplace plans.
Covered (preferred drug)Qualification pathways
You can qualify through any one of these.
Initial approval for T2DM
All of:
- Diagnosis of type 2 diabetes mellitus
- Patient is 18 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 18 years of age or older
Not covered when
- Use in patients younger than 18 years of age is considered investigational
- Use for any non-FDA approved indication is considered investigational
Policy note: Ozempic 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. The policy covers Ozempic for diabetes under this policy (00324). The CV risk reduction and CKD indications for Ozempic are acknowledged in the background/FDA sections but no separate PA criteria are established for those indications in this policy — only the diabetes indication has explicit PA criteria.
Policy effective May 1, 2026 · verified June 2, 2026 · source: GLP-1 Agonistsfor Diabetes · View policy document (PDF)