Medicare Advantage
Covered with requirementsWhat you need to qualify
- A1C of 6.5% or higher
Qualification pathways
You can qualify through any one of these.
Ongoing T2DM treatment with chart note confirmation
All of:
- Medical records (e.g., chart notes) confirming diagnosis of T2DM for ongoing treatment
T2DM diagnosis confirmed by laboratory values
All of:
- Medical records (e.g., chart notes) confirming diagnosis of T2DM
Plus any one of:
- A1c >= 6.5%
- 2-hour plasma glucose >= 200 mg/dL during OGTT
- Symptoms of hyperglycemia or hyperglycemic crisis AND random plasma glucose >= 200 mg/dL
- Fasting plasma glucose >= 126 mg/dL (fasted at least 8 hours)
Documentation to bring
- Medical records (e.g., chart notes) confirming diagnosis of T2DM
- If lab confirmation pathway: lab result showing A1c >= 6.5%, OR 2-hour PG >= 200 mg/dL during OGTT, OR random plasma glucose >= 200 mg/dL with hyperglycemia symptoms, OR fasting plasma glucose >= 126 mg/dL
- Confirmation that patient has no FDA-labeled contraindications to the requested agent
- Confirmation that patient will not use the agent in combination with another GLP-1 agonist or GLP-1-containing agent
- Confirmation that patient will not use the agent in combination with a DPP-4 inhibitor
Quantity limits
- all strengths — 30-day supply
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
Not covered when
- Concurrent use with another GLP-1 agonist or GLP-1-containing agent
- Concurrent use with a DPP-4 inhibitor
- Use for weight loss only
Policy note: Coverage duration is plan year with 30-day supply per dispensing. Excluded when used for weight loss only. Two pathways to qualify: (1) ongoing T2DM treatment confirmed by chart notes, or (2) new T2DM diagnosis confirmed by chart notes plus qualifying lab value.
Policy effective June 1, 2026 · verified June 2, 2026 · source: 2026_partd_prior_authorization_criteria_ma.pdf