Applies to Employer and ACA Marketplace plans.
Covered (preferred drug)Qualification pathways
You can qualify through any one of these.
Continuation of therapy (Ozempic as preferred agent)
All of:
- Diagnosis of type 2 diabetes
- A1C ≥ 6.5% confirmed by lab test or medical records
- Patient is eligible for continuation of therapy: treated with a preferred agent within the past 90 days (starting on samples is not approvable), OR prescriber states patient has been treated with a preferred agent within the past 90 days and is at risk if therapy with a preferred agent is discontinued
- 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
New start as preferred agent
All of:
- Diagnosis of type 2 diabetes
- A1C ≥ 6.5% confirmed by lab test or medical records
- Ozempic is a preferred agent
- 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%
- For continuation: documentation of treatment with preferred agent within past 90 days (samples do not qualify)
- 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: Ozempic (injection) is listed as a preferred agent. Rybelsus (oral semaglutide tablet) shares the same PA criteria module and is also covered. Fill limit of one GLP-1 agent at one strength per 28 days applies across the class. The PA criteria module covers diabetes indication; CV risk reduction and CKD are FDA-labeled indications for Ozempic but the PA criteria module is structured around T2DM diagnosis without separate pathways for CV or CKD indications.
Policy effective May 11, 2026 · verified June 2, 2026 · source: Nd GLP-1 Paql Prog Sum · View policy document (PDF)