Applies to Employer plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
CKD indication - new patient (requires T2DM + prior therapy or comorbidity)
All of:
- Diagnosis of type 2 diabetes mellitus (medical record documentation required)
- Chronic kidney disease diagnosis
- Requested product will not be taken concomitantly with a DPP-4 containing agent
- Requested product will not be taken concomitantly with another GLP-1 agonist
Plus any one of:
- Patient has tried and had an inadequate response, intolerance, or hypersensitivity to an agent containing metformin, sulfonylurea, or insulin
- Patient has an FDA labeled contraindication to metformin
- Patient has a diagnosis of, or is at high risk for, atherosclerotic cardiovascular disease, heart failure, chronic kidney disease, and/or MASH
CKD indication - continuity of care
All of:
- Diagnosis of type 2 diabetes mellitus (medical record documentation required)
- Prescriber states patient is currently being treated with the requested agent within the past 90 days and is at risk if therapy is changed
- Requested product will not be taken concomitantly with a DPP-4 containing agent
- Requested product will not be taken concomitantly with another GLP-1 agonist
Documentation to bring
- Medical record documentation of type 2 diabetes mellitus diagnosis
- Documentation of chronic kidney disease diagnosis
- Documentation of prior trial with inadequate response, intolerance, or hypersensitivity to metformin, sulfonylurea, or insulin OR FDA labeled contraindication to metformin OR diagnosis of/high risk for ASCVD, heart failure, CKD, or MASH (OR attestation that patient is currently on this agent within the past 90 days and at risk if changed)
- Attestation that requested product will not be taken concomitantly with a DPP-4 containing agent
- Attestation that requested product will not be taken concomitantly with another GLP-1 agonist
Quantity limits
- 0.25mg/dose (2mg/3mL pen), 0.5mg/dose (2mg/3mL pen) — 3 mL (1 pen)
- 1mg/dose (4mg/3mL pen) — 3 mL (1 pen)
- 2mg/dose (8mg/3mL pen) — 3 mL (1 pen)
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
Not covered when
- Concomitant use with DPP-4 containing agent
- Concomitant use with another GLP-1 agonist
Policy note: CKD indication for Ozempic injection added per Feb 2025 policy update. The policy does not specify separate or different PA criteria for the CKD indication beyond T2DM diagnosis requirement and step therapy; CKD diagnosis itself can satisfy the comorbidity exception to metformin step therapy. T2DM is required concurrently per FDA labeling cited.
Policy effective May 1, 2026 · verified June 2, 2026 · source: GLP-1 Agonists Nc Standard · View policy document (PDF)