Employer / Commercial Insurance
Covered (preferred drug)What you need to qualify
- Age 18 and older
- Diagnosis documented with a code
Qualification pathways
You can qualify through any one of these.
Initial approval for T2DM
All of:
- Age >= 18 years
- Not being prescribed concurrently with another GLP-1 or GLP-1/GIP receptor agonist
- Diagnosis of Type 2 Diabetes Mellitus confirmed by lab or ICD-10 code
Plus any one of:
- History of antidiabetic medication use (insulin, sulfonylureas, metformin, SGLT-2 inhibitor, DPP-IV inhibitor, or other)
- History of intolerance, contraindication, clinically significant adverse effects, or inadequate response to metformin
- ICD-10 diagnosis code or documentation of chronic kidney disease (CKD)
- ICD-10 diagnosis code or documentation of established atherosclerotic cardiovascular disease (ASCVD)
Documentation to bring
- ICD-10 diagnosis code for Type 2 Diabetes Mellitus OR lab confirmation (HbA1C > 6.5%, FPG >= 126 mg/dL, 2-hour glucose >= 200 mg/dL on OGTT, or random glucose >= 200 mg/dL with classic hyperglycemia symptoms)
- Documentation or claims history of prior antidiabetic medication use OR documentation of metformin intolerance/contraindication/adverse effects/inadequate response OR ICD-10 or documentation of CKD or established ASCVD
Approval and renewal
- Initial approval: 12 months
Not covered when
- Concurrent use with another GLP-1 or GLP-1/GIP receptor agonist
- Type 1 diabetes
Policy note: Ozempic is Preferred subject to PA and Quality Care Dosing (policy #621B). Age minimum is 18. For Ozempic specifically, the step-4 criteria include CKD or established ASCVD as qualifying alternatives to prior antidiabetic medication use. CKD expanded indication added 8/1/2025. Coverage for weight loss indication is in related policy #572.
Policy effective May 1, 2026 · verified June 2, 2026 · source: 056%20Glucagon-like%20Peptide-1%20(GLP-1)%20Receptor%20Agonists%20and%20Related%20Drugs%20for%20the%20Treatment%20of%20Type%202%20Diabetes.pdf