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
- Established cardiovascular disease (MI, stroke, revascularization, TIA, unstable_angina, amputation, and coronary_artery_disease)
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
CV Risk Reduction - Ozempic in T2DM with Established CVD or Multiple CV Risk Factors
All of:
- Diagnosis of type 2 diabetes
- A1C >= 6.5% confirmed by lab test
- Requested agent will be used to reduce 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 or GLP-1/GIP receptor agonist
- No FDA labeled contraindications to the requested agent
Plus any one of:
- Patient has established cardiovascular disease (e.g., MI, stroke, any revascularization procedure, TIA, unstable angina, amputation, symptomatic or asymptomatic coronary artery disease)
- Patient has multiple cardiovascular risk factors (e.g., hypertension, dyslipidemia, family history of cardiovascular disease, smoking)
Documentation to bring
- Documentation of type 2 diabetes diagnosis
- Lab test results showing A1C >= 6.5%
- Documentation of established cardiovascular disease (e.g., MI, stroke, revascularization, TIA, unstable angina, amputation, CAD) or documentation of multiple cardiovascular risk factors (HTN, dyslipidemia, family history of CVD, smoking)
- Prescriber statement that the requested agent will be used to reduce risk of major adverse cardiovascular events
- 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. Patient must still have T2DM diagnosis and A1C >= 6.5%. Continuation pathway also available 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: CV risk reduction indication for Ozempic applies in patients with T2DM and established CVD or multiple CV risk factors. The policy does not exclude patients who have NOT failed metformin/insulin if the CV risk pathway is used — metformin/insulin trial is NOT required for this pathway. T2DM diagnosis and A1C >= 6.5% are still required. This is a bundled policy covering all GLP-1 indications under a single PA framework; the CV risk pathway is a qualifying exception to the metformin/insulin step therapy requirement.
source: Pa policy