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BCBS Rhode Island

Does BCBS Rhode Island cover Ozempic?

Yes. BCBS Rhode Island covers Ozempic for type 2 diabetes with prior authorization. Other policy requirements and your plan's benefits also apply.

Policy document

  • Employer and ACA Marketplace: Covered (preferred drug). See the qualification pathways below.

Earliest policy review June 2, 2026. How we verify · Check your exact plan

Full requirements: Ozempic for Type 2 Diabetes (2 plan types)

Applies to Employer and ACA Marketplace plans.

Covered (preferred drug)

Qualification pathways

You can qualify through any one of these.

Continuation of therapy

All of:

  • Diagnosis of type 2 diabetes mellitus
  • A1C ≥ 6.5% confirmed by lab test (lab results or medical records required)
  • Age within FDA labeling for indication OR support for off-label age use
  • Will NOT use in combination with a DPP-4 containing agent
  • Will NOT use in combination with another GLP-1 receptor agonist
  • No FDA labeled contraindications to requested agent

Plus any one of:

  • Patient has been treated with an eligible continuation agent (Ozempic, Rybelsus, Trulicity, Mounjaro, liraglutide, Bydureon BCise) within the past 90 days (not starting on samples)
  • Prescriber states patient has been treated with an eligible continuation agent within the past 90 days (not starting on samples) AND patient is at risk if therapy is discontinued

New therapy - step therapy met

All of:

  • Diagnosis of type 2 diabetes mellitus
  • A1C ≥ 6.5% confirmed by lab test (lab results or medical records required)
  • Age within FDA labeling for indication OR support for off-label age use
  • Will NOT use in combination with a DPP-4 containing agent
  • Will NOT use in combination with another GLP-1 receptor agonist
  • No FDA labeled contraindications to requested agent

Plus any one of:

  • Tried and had inadequate response to at least one prerequisite agent containing metformin or insulin
  • Intolerance or hypersensitivity to metformin or insulin
  • FDA labeled contraindication to BOTH metformin AND insulin

New therapy - CV risk reduction pathway

All of:

  • Diagnosis of type 2 diabetes mellitus
  • A1C ≥ 6.5% confirmed by lab test (lab results or medical records required)
  • Patient has established cardiovascular disease (e.g., MI, stroke, any revascularization, TIA, unstable angina, amputation, symptomatic or asymptomatic CAD) OR multiple cardiovascular risk factors (e.g., hypertension, dyslipidemia, family history of CVD, smoking)
  • Requested agent will be used to reduce the risk of major adverse cardiovascular events (CV death, non-fatal MI, or non-fatal stroke)
  • Age within FDA labeling for indication OR support for off-label age use
  • Will NOT use in combination with a DPP-4 containing agent
  • Will NOT use in combination with another GLP-1 receptor agonist
  • No FDA labeled contraindications to requested agent

New therapy - CKD pathway

All of:

  • Diagnosis of type 2 diabetes mellitus
  • A1C ≥ 6.5% confirmed by lab test (lab results or medical records required)
  • Patient has chronic kidney disease (CKD)
  • Requested agent will be used to reduce the risk of sustained eGFR decline, end-stage kidney disease, and cardiovascular death
  • Age within FDA labeling for indication OR support for off-label age use
  • Will NOT use in combination with a DPP-4 containing agent
  • Will NOT use in combination with another GLP-1 receptor agonist
  • No FDA labeled contraindications to requested agent

New therapy - MASH pathway

All of:

  • Diagnosis of type 2 diabetes mellitus
  • A1C ≥ 6.5% confirmed by lab test (lab results or medical records required)
  • Patient has diagnosis of noncirrhotic MASH with moderate to advanced liver fibrosis (F2 to F3)
  • Age within FDA labeling for indication OR support for off-label age use
  • Will NOT use in combination with a DPP-4 containing agent
  • Will NOT use in combination with another GLP-1 receptor agonist
  • No FDA labeled contraindications to requested agent

Documentation to bring

  • Documentation of type 2 diabetes mellitus diagnosis
  • Lab results confirming A1C ≥ 6.5% or medical records confirming diabetes diagnosis
  • Documentation of metformin or insulin trial with inadequate response (≥90 days), OR documentation of intolerance/hypersensitivity/contraindication to metformin or insulin — OR documentation of qualifying CV disease/risk factors, CKD, or MASH with F2-F3 fibrosis — OR documentation of prior treatment with eligible continuation agent within past 90 days
  • Confirmation patient will not use concurrently with a DPP-4 agent
  • Confirmation patient will not use concurrently with another GLP-1 receptor agonist
  • Confirmation of no FDA labeled contraindications to requested agent

Quantity limits

  • 2 MG/3ML, 4 MG/3ML, 8 MG/3ML — 1 pen per 28 days

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • Renewal: Patient must have been treated with an eligible continuation agent within the past 90 days (starting on samples not approvable), OR prescriber states patient has been treated within the past 90 days and is at risk if therapy is discontinued.

Not covered when

  • Concurrent use with DPP-4 containing agents
  • Concurrent use with another GLP-1 receptor agonist
  • Personal or family history of MTC or MEN 2 (per FDA contraindication)
  • Prior serious hypersensitivity reaction to semaglutide or product components

Policy note: Ozempic injection (semaglutide) is listed as a preferred/target agent. Also includes Ozempic tablets (semaglutide) per FDA indication table - same PA criteria apply. The policy covers Ozempic for T2DM, CV risk reduction in T2DM with established CVD, and CKD indication (reduce sustained eGFR decline, ESKD, and CV death in T2DM with CKD). Fill limit of one GLP-1 agent and one strength per 28 days. Length of approval is 12 months.

Policy effective May 25, 2026 · verified June 2, 2026 · source: Ri GLP-1 Agonists Paql Prog Sum · View policy document (PDF)

Open on its own page →

Full requirements: Ozempic for Heart Disease Risk Reduction (2 plan types)

Applies to Employer and ACA Marketplace plans.

Covered (preferred drug)

Qualification pathways

You can qualify through any one of these.

CV risk reduction in T2DM

All of:

  • Diagnosis of type 2 diabetes mellitus
  • A1C ≥ 6.5% confirmed by lab test (lab results or medical records required)
  • Requested agent will be used to reduce the risk of major adverse cardiovascular events (CV death, non-fatal MI, or non-fatal stroke)
  • Age within FDA labeling for indication OR support for off-label age use
  • Will NOT use in combination with a DPP-4 containing agent
  • Will NOT use in combination with another GLP-1 receptor agonist
  • No FDA labeled contraindications to requested agent

Plus any one of:

  • Patient has established cardiovascular disease (e.g., MI, stroke, any revascularization, TIA, unstable angina, amputation, symptomatic or asymptomatic CAD)
  • Patient has multiple cardiovascular risk factors (e.g., hypertension, dyslipidemia, family history of CVD, smoking)

Documentation to bring

  • Documentation of type 2 diabetes mellitus diagnosis
  • Lab results confirming A1C ≥ 6.5% or medical records confirming diabetes diagnosis
  • Documentation of established cardiovascular disease or multiple cardiovascular risk factors
  • Statement that agent is being used to reduce risk of MACE
  • Confirmation patient will not use concurrently with a DPP-4 agent
  • Confirmation patient will not use concurrently with another GLP-1 receptor agonist
  • Confirmation of no FDA labeled contraindications to requested agent

Quantity limits

  • 2 MG/3ML, 4 MG/3ML, 8 MG/3ML — 1 pen per 28 days

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • Renewal: Patient must have been treated with an eligible continuation agent within the past 90 days (not starting on samples), OR prescriber states patient has been treated within past 90 days and is at risk if therapy is discontinued.

Not covered when

  • Concurrent use with DPP-4 containing agents
  • Concurrent use with another GLP-1 receptor agonist
  • Personal or family history of MTC or MEN 2 (per FDA contraindication)
  • Prior serious hypersensitivity reaction to semaglutide or product components

Policy note: CV risk reduction indication for Ozempic requires T2DM diagnosis AND established CVD or multiple CV risk factors. This policy requires T2DM (does not exclude diabetes for this indication — it is specifically for T2DM patients). Policy also covers Ozempic tablets for CV risk reduction in T2DM at high risk for CV events.

Policy effective May 25, 2026 · verified June 2, 2026 · source: Ri GLP-1 Agonists Paql Prog Sum · View policy document (PDF)

Open on its own page →

Full requirements: Ozempic for Kidney Disease (CKD) (2 plan types)

Applies to Employer and ACA Marketplace plans.

Covered (preferred drug)

Qualification pathways

You can qualify through any one of these.

CKD risk reduction in T2DM

All of:

  • Diagnosis of type 2 diabetes mellitus
  • A1C ≥ 6.5% confirmed by lab test (lab results or medical records required)
  • Patient has chronic kidney disease (CKD)
  • Requested agent will be used to reduce the risk of sustained eGFR decline, end-stage kidney disease, and cardiovascular death
  • Age within FDA labeling for indication OR support for off-label age use
  • Will NOT use in combination with a DPP-4 containing agent
  • Will NOT use in combination with another GLP-1 receptor agonist
  • No FDA labeled contraindications to requested agent

Documentation to bring

  • Documentation of type 2 diabetes mellitus diagnosis
  • Lab results confirming A1C ≥ 6.5% or medical records confirming diabetes diagnosis
  • Documentation of chronic kidney disease (CKD) diagnosis
  • Statement that agent is being used to reduce risk of sustained eGFR decline, ESKD, and cardiovascular death
  • Confirmation patient will not use concurrently with a DPP-4 agent
  • Confirmation patient will not use concurrently with another GLP-1 receptor agonist
  • Confirmation of no FDA labeled contraindications to requested agent

Quantity limits

  • 2 MG/3ML, 4 MG/3ML, 8 MG/3ML — 1 pen per 28 days

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • Renewal: Patient must have been treated with an eligible continuation agent within the past 90 days (not starting on samples), OR prescriber states patient has been treated within past 90 days and is at risk if therapy is discontinued.

Not covered when

  • Concurrent use with DPP-4 containing agents
  • Concurrent use with another GLP-1 receptor agonist
  • Personal or family history of MTC or MEN 2 (per FDA contraindication)
  • Prior serious hypersensitivity reaction to semaglutide or product components

Policy note: CKD indication for Ozempic (injection) is explicitly listed in the FDA indication table: to reduce the risk of sustained eGFR decline, end-stage kidney disease, and cardiovascular death in adults with T2DM and CKD. The policy clinical criteria include a specific CKD pathway. No specific eGFR or UACR thresholds are specified in the PA criteria beyond CKD diagnosis.

Policy effective May 25, 2026 · verified June 2, 2026 · source: Ri GLP-1 Agonists Paql Prog Sum · View policy document (PDF)

Open on its own page →

Questions people ask
Does BCBS Rhode Island cover Ozempic?
Yes. BCBS Rhode Island covers Ozempic for type 2 diabetes with prior authorization. Other policy requirements and your plan's benefits also apply.
How long does a Ozempic approval last with BCBS Rhode Island?
Type 2 Diabetes — Applies to Employer and ACA Marketplace plans. Initial approval: 12 months. Renewal: every 12 months. Heart Disease Risk Reduction — Applies to Employer and ACA Marketplace plans. Initial approval: 12 months. Renewal: every 12 months. Kidney Disease (CKD) — Applies to Employer and ACA Marketplace plans. Initial approval: 12 months. Renewal: every 12 months.
What does BCBS Rhode Island require to renew Ozempic?
Type 2 Diabetes — Applies to Employer and ACA Marketplace plans. Patient must have been treated with an eligible continuation agent within the past 90 days (starting on samples not approvable), OR prescriber states patient has been treated within the past 90 days and is at risk if therapy is discontinued. Heart Disease Risk Reduction — Applies to Employer and ACA Marketplace plans. Patient must have been treated with an eligible continuation agent within the past 90 days (not starting on samples), OR prescriber states patient has been treated within past 90 days and is at risk if therapy is discontinued. Kidney Disease (CKD) — Applies to Employer and ACA Marketplace plans. Patient must have been treated with an eligible continuation agent within the past 90 days (not starting on samples), OR prescriber states patient has been treated within past 90 days and is at risk if therapy is discontinued.
How current is this information?
The oldest review date among the policies on this page is June 2, 2026. Each policy's effective and verification dates appear with its requirements. Confirm current benefits with your plan.

Also under BCBS Rhode Island: Mounjaro, Wegovy, Zepbound

Ozempic under other plans: BCBS Alabama, BCBS Arizona, BCBS Arkansas, BCBS Kansas, BCBS Louisiana, BCBS Massachusetts, BCBS Michigan, BCBS Minnesota

All insurance plans · All medications

Summary of BCBS Rhode Island's written policy, not a guarantee of coverage. Plans vary by employer and benefit design.