Employer / Commercial Insurance
Covered (preferred drug)What you need to qualify
- Age 18 and older
- A1C of 6.5% or higher
- Diagnosis documented with a code
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
CKD Indication - Ozempic in T2DM with CKD
All of:
- Diagnosis of type 2 diabetes
- A1C >= 6.5% confirmed by lab test
- Patient has chronic kidney disease (CKD)
- Requested agent will be used to reduce risk of sustained eGFR decline, end-stage kidney disease, and cardiovascular death
- 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 or GLP-1/GIP receptor agonist
- No FDA labeled contraindications to the requested agent
Documentation to bring
- Documentation of type 2 diabetes diagnosis
- Lab test results showing A1C >= 6.5%
- Documentation of chronic kidney disease (CKD) diagnosis
- Prescriber statement that the requested agent will be used to reduce risk of sustained eGFR decline, end-stage kidney disease, and cardiovascular death
- Confirmation that patient is not using a DPP-4 inhibitor concurrently
- Confirmation that patient is not using another GLP-1 or GLP-1/GIP receptor agonist concurrently
Quantity limits
- 2 MG/3ML — 1 pen per 28 days
- 4 MG/3ML — 1 pen per 28 days
- 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 approved via same criteria as initial approval, or via the continuation of therapy pathway if patient has been on a preferred agent within past 90 days.
Not covered when
- Concurrent use with DPP-4 inhibitors
- Concurrent use with another GLP-1 or GLP-1/GIP receptor agonist
- Personal or family history of MTC or MEN 2
- Type 1 diabetes
Policy note: CKD indication for Ozempic (to reduce risk of sustained eGFR decline, ESKD, and cardiovascular death in T2DM with CKD) is recognized as an exception pathway to the metformin/insulin step therapy requirement. Specific eGFR or UACR thresholds are not defined in this policy document. T2DM diagnosis and A1C >= 6.5% are still required per the overall PA framework.
source: Pa policy