Employer / Commercial Insurance
Covered (preferred drug)What you need to qualify
- A1C of 6.5% or higher
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
Continuation of therapy
All of:
- Diagnosis of type 2 diabetes
- A1C >= 6.5% confirmed by lab test
- Requested agent is eligible for continuation of therapy (Ozempic is listed as eligible)
- No FDA labeled contraindications to the requested agent
- Not using in combination with a DPP-4 containing agent
- Not using in combination with another GLP-1 receptor agonist
Plus any one of:
- Patient has been treated with a preferred agent within the past 90 days (not starting on samples)
- Prescriber states patient has been treated with a preferred agent within the past 90 days and is at risk if therapy is discontinued
New therapy — step therapy failure or exception
All of:
- Diagnosis of type 2 diabetes
- A1C >= 6.5% confirmed by lab test
- No FDA labeled contraindications to the requested agent
- Not using in combination with a DPP-4 containing agent
- Not using in combination with another GLP-1 receptor agonist
- Patient age is within FDA labeling for the requested indication OR there is support for use at patient's age
Plus any one of:
- Tried and had inadequate response to ONE prerequisite agent containing metformin or insulin
- Intolerance or hypersensitivity to metformin or insulin
- FDA labeled contraindication to BOTH metformin AND insulin
- Patient has established cardiovascular disease (e.g., MI, stroke, revascularization, TIA, unstable angina, amputation, CAD) OR multiple CV risk factors (HTN, dyslipidemia, family history of CVD, smoking) AND requested agent will be used to reduce risk of MACE
- Patient has chronic kidney disease (CKD) AND requested agent will be used to reduce risk of sustained eGFR decline, ESKD, and cardiovascular death
- Patient has diagnosis of noncirrhotic MASH with moderate to advanced liver fibrosis (F2 to F3)
Documentation to bring
- Lab test confirming T2DM diagnosis (e.g., A1C >= 6.5%) or medical records
- Documentation of type 2 diabetes diagnosis
- Documentation of one of: inadequate response to metformin or insulin trial, intolerance/hypersensitivity to metformin or insulin, contraindication to both metformin and insulin, established CV disease or multiple CV risk factors, CKD diagnosis, or noncirrhotic MASH with F2-F3 fibrosis — OR documentation of prior preferred agent use within past 90 days for continuation
- Confirmation that patient will not use requested agent in combination with a DPP-4 containing agent
- Confirmation that patient will not use requested agent in combination with another GLP-1 receptor agonist
Quantity limits
- 2 MG/3ML — 1 pen per 28 days
- 4 MG/3ML — 1 pen per 28 days
- 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 has been 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 is discontinued. Initial A1C and step therapy requirements are not re-verified at continuation.
Not covered when
- Combination use with a DPP-4 containing agent (e.g., Januvia, Onglyza, Tradjenta, etc.) for the requested indication
- Combination use with another GLP-1 receptor agonist
- Any FDA labeled contraindication to the requested agent
Policy note: Document covers the WY NetR-Commercial Custom formulary administered by Prime Therapeutics. Ozempic is listed as a preferred agent. Fill limit of one GLP-1 agent and one strength per 28 days applies. Quantity limit exceptions may be approved for: switching strengths (inadequate response to higher, or intolerance to lower), switching GLP-1 agents (inadequate response, intolerance/hypersensitivity, or contraindication to prior agent). One-time approval for titration dose extension requests and for replacement of another GLP-1 agent/strength if within QL but over fill limit. Non-preferred agents (Byetta, Exenatide, Victoza) require trial/failure of preferred agents per step-therapy structure implied by the non-preferred tier designation. Rybelsus (oral semaglutide) shares the same clinical criteria and is listed co-branded with Ozempic for the semaglutide tablet formulation.
Policy effective May 11, 2026 · verified June 4, 2026 · source: WY_GLP-1_Agonists_PAQL_ProgSum.pdf