Applies to Employer and ACA Marketplace plans.
Covered (preferred drug)Qualification pathways
You can qualify through any one of these.
CV risk reduction via T2DM diagnosis pathway
All of:
- Diagnosis of type 2 diabetes
- A1C ≥ 6.5% confirmed by lab test or medical records
- FDA labeled indication for CV risk reduction applies (established cardiovascular disease with T2DM)
- Patient age is within FDA labeling for the requested indication, OR there is support for using the requested agent for the patient's age
- Patient will NOT be using the requested agent in combination with a DPP-4 containing agent
- Patient will NOT be using the requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications to the requested agent
Documentation to bring
- Documentation of type 2 diabetes diagnosis
- Lab test results or medical records confirming A1C ≥ 6.5%
- Documentation of established cardiovascular disease
- Confirmation patient is not using a DPP-4 inhibitor concurrently
- Confirmation patient is not using another GLP-1 receptor agonist concurrently
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
- Concurrent use with DPP-4 inhibitor
- Concurrent use with another GLP-1 receptor agonist
- FDA labeled contraindications (personal or family history of MTC or MEN 2; prior serious hypersensitivity reaction)
Policy note: The PA criteria module does not create a separate pathway specifically for the CV risk reduction indication. The policy covers Ozempic under the T2DM diagnosis criteria module; the FDA-labeled CV risk reduction indication is acknowledged in the FDA indication table. CV risk reduction is covered under the same PA criteria as diabetes (T2DM diagnosis + A1C ≥ 6.5%). The policy references FDA labeling compliance as part of criteria (criterion 3.B.2). Specific CV risk reduction criteria (e.g., established CVD requirement, GDMT) are not separately enumerated in this PA module.
Policy effective May 11, 2026 · verified June 2, 2026 · source: Nd GLP-1 Paql Prog Sum · View policy document (PDF)