Employer / Commercial Insurance
Covered (preferred drug)What you need to qualify
- A1C of 6.5% or higher
- Established cardiovascular disease
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
CV Risk Reduction in T2DM with Established CVD
All of:
- Patient has diagnosis of type 2 diabetes mellitus
- Diagnosis confirmed by lab (A1C >= 6.5%)
- Established cardiovascular disease
- Age within FDA labeling for requested indication OR support provided for requested age
- 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 established cardiovascular disease
- 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
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
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.
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
Policy note: Policy states Ozempic is FDA approved to reduce risk of major adverse cardiovascular events in adults with T2DM and established CVD. The policy criteria do not separate CV risk reduction from diabetes criteria in explicit steps — the same general pathway applies with T2DM diagnosis and established CVD as the indication. Specific qualifying CV events (MI, stroke, PAD) are not enumerated in this policy. Since Ozempic is preferred, no GLP-1 step therapy is required.
Policy effective November 5, 2025 · verified June 2, 2026 · source: policy-212.html