Employer / Commercial Insurance
Covered (preferred drug)What you need to qualify
- A1C of 6.5% or higher
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
Preferred GLP-1 - Prior Use within 90 Days
All of:
- Patient has diagnosis of type 2 diabetes mellitus
- Diagnosis confirmed by lab (A1C >= 6.5%)
- Age within FDA labeling for requested indication OR support provided for requested age
- Patient treated with a preferred agent within the past 90 days (samples not approvable)
- Will NOT be used in combination with a DPP-4 containing agent
- Will NOT be used in combination with another GLP-1 receptor agonist
- No FDA labeled contraindications to the requested agent
Preferred GLP-1 - New Start
All of:
- Patient has diagnosis of type 2 diabetes mellitus
- Diagnosis confirmed by lab (A1C >= 6.5%)
- Age within FDA labeling for requested indication OR support provided for requested age
- Ozempic is a preferred GLP-1 agent
- Will NOT be used in combination with a DPP-4 containing agent
- Will NOT be used in combination with another GLP-1 receptor agonist
- No FDA labeled contraindications to the requested agent
Documentation to bring
- Documentation of type 2 diabetes mellitus diagnosis
- Lab result confirming A1C >= 6.5%
- Documentation of patient age within FDA labeling OR clinical support for off-label age use
- Attestation that patient will not use in combination with a DPP-4 containing agent
- Attestation that patient will not use in combination with another GLP-1 receptor agonist
- Attestation of no FDA labeled contraindications to the requested agent
- If prior use pathway: documentation of prior preferred agent use within past 90 days (samples not acceptable)
Quantity limits
- 0.25mg dose, 0.5mg dose — 1 pen (2mg/1.5mL) per month
- 1mg dose — 1 pen (4mg/3mL) per month
- 2mg dose — 1 pen (8mg/3mL) per month
- 1.5mg tablet, 4mg tablet, 9mg tablet — 1 tablet per day
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- To renew, the plan looks for Patient must have had clinical benefit with the requested agent. No re-verification of T2DM diagnosis, A1C threshold, or step therapy at renewal.
Not covered when
- Combination use with DPP-4 containing agents
- Combination use with another GLP-1 receptor agonist
- FDA labeled contraindications to the requested agent
- Use for non-FDA approved indications (considered investigational unless excluded by contract)
Policy note: Ozempic (injection) and Rybelsus (tablet/oral semaglutide) are both listed as preferred agents. Policy includes Ozempic tablets (1.5mg, 4mg, 9mg) as of 05-04-2026 revision at parity with Rybelsus tablets. Ozempic is a preferred agent so no step therapy through other GLP-1s is required. Non-preferred agents require trial/failure of TWO preferred agents (90 days each). Metformin step therapy was removed as of 04-01-2026.
Policy effective November 5, 2025 · verified June 2, 2026 · source: policy-212.html