Applies to Employer plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
CV risk reduction - new patient (requires T2DM + prior therapy or comorbidity)
All of:
- Diagnosis of type 2 diabetes mellitus (medical record documentation required)
- Established cardiovascular disease OR high risk for cardiovascular events (per FDA labeling for Ozempic/Rybelsus)
- 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
CV risk reduction - 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 established cardiovascular disease or high cardiovascular risk
- 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: This policy does not have separate approval criteria for the CV risk reduction indication vs. the diabetes indication — all approvals require T2DM diagnosis plus prior therapy or comorbidity. The CV risk reduction indication is recognized per FDA labeling cited in the document. T2DM is REQUIRED (does not exclude diabetes). Rybelsus also shares the CV risk reduction indication per this policy (Nov 2025 update).
Policy effective May 1, 2026 · verified June 2, 2026 · source: GLP-1 Agonists Nc Standard · View policy document (PDF)