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)