Applies to Employer and ACA Marketplace plans.
Covered (preferred drug)Qualification pathways
You can qualify through any one of these.
New Start — Preferred Agent
All of:
- Diagnosis of type 2 diabetes mellitus
- A1C ≥ 6.5% confirmed by lab test (lab results or medical records required)
- Ozempic (semaglutide) is a preferred agent — no step therapy required
- Age within FDA labeling for the requested indication OR support for use at patient's age
- Patient will NOT use requested agent in combination with a DPP-4 inhibitor
- Patient will NOT use requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications to Ozempic
Continuation of Therapy
All of:
- Diagnosis of type 2 diabetes mellitus
- A1C ≥ 6.5% confirmed by lab test
- Ozempic is listed as eligible for continuation of therapy
- Age within FDA labeling for the requested indication OR support for use at patient's age
- Patient will NOT use requested agent in combination with a DPP-4 inhibitor
- Patient will NOT use requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications to Ozempic
Plus any one of:
- Patient has been treated with a preferred agent (not samples) within the past 90 days
- Prescriber states patient has been treated with a preferred agent within the past 90 days (not samples) and is at risk if therapy is discontinued
Documentation to bring
- Documentation of type 2 diabetes mellitus diagnosis
- Lab result confirming A1C ≥ 6.5% (or medical records)
- Attestation that patient will not use Ozempic in combination with a DPP-4 inhibitor
- Attestation that patient will not use Ozempic in combination with another GLP-1 receptor agonist
- Confirmation that patient has no FDA labeled contraindications to Ozempic
- For continuation: documentation or prescriber statement of prior preferred agent use within past 90 days (samples not approvable)
Quantity limits
- 2 MG/3ML, 4 MG/3ML, 8 MG/3ML — 1 pen
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
Not covered when
- Combination use with DPP-4 inhibitor agents
- Combination use with another GLP-1 receptor agonist
- FDA labeled contraindications to Ozempic (personal or family history of MTC or MEN2; prior serious hypersensitivity)
Policy note: Ozempic (semaglutide) is listed as a preferred agent. The FDA label also includes indications for CV risk reduction and CKD in T2DM patients, but this PA policy document only establishes criteria under a diabetes (glycemic control) module — no separate CV risk reduction or CKD criteria are established in this document. The BCBS MN Step Therapy Supplement also applies. Quantity limit: 1 pen per 28 days across all strengths.
Policy effective April 1, 2026 · verified June 5, 2026 · source: BCBS Minnesota ACA Marketplace prior authorization policy · View policy document (PDF)