Employer / Commercial Insurance
Covered (preferred drug)What you need to qualify
- A1C of 6.5% or higher
- Diagnosis documented with a code
- Lab results confirming eligibility
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
- To renew, the plan looks for 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_GLP1_Agonists_PAQL_ProgSum.pdf