Does Capital BlueCross cover Ozempic?

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Documentation of type 2 diabetes diagnosis
• Lab test results confirming diagnosis (e.g., A1C ≥ 6.5%) or supporting medical records
• Documentation that patient will not be using the agent in combination with a DPP-4 inhibitor
• Documentation that patient will not be using the agent in combination with another GLP-1 receptor agonist
• Confirmation that patient has no FDA labeled contraindications to the requested agent
• For continuation: documentation of prior treatment with a preferred agent within the past 90 days, or prescriber attestation with clinical rationale for why switching preferred agent poses risk

Quantity limits

• 2 MG/3ML — 1 pen
• 4 MG/3ML — 1 pen
• 8 MG/3ML — 1 pen

Approval and renewal

• Initial approval: 12 months
• Renewal: every 12 months
• Renewal: Continuation requires patient has been treated with a preferred agent within the past 90 days (starting on samples is not approvable); prescriber may attest patient has been treated with a preferred agent within 90 days and is at risk if therapy is discontinued.

Not covered when

• Combination use with DPP-4 inhibitor-containing agents
• Combination use with another GLP-1 receptor agonist
• FDA labeled contraindications to the requested agent (including personal or family history of MTC or MEN 2)
• Starting on samples is not approvable for continuation of therapy

Policy note: Policy applies to Capital Blue Cross Commercial, Small Group, Individual Exchange, CHIP, Net Results A, Net Results F. Ozempic (injectable semaglutide) is listed as a preferred agent. The FDA indications in the document also include CV risk reduction and CKD for Ozempic injection; however, the PA clinical criteria module covers all agents under a single 'type 2 diabetes' diagnosis criterion without separate indication-specific pathways for CV or CKD indications. Ozempic tablets (semaglutide) share the same PA criteria. Fill limit: one GLP-1 agent and one strength per 28 days. Semaglutide tablets (1.5 mg, 4 mg, 9 mg) are shared between Ozempic and Rybelsus NDCs per the quantity limit table.

Policy effective May 11, 2026 · verified June 5, 2026 · source: Capital BlueCross Employer / Commercial Insurance prior authorization policy · View policy document (PDF)

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Documentation of established cardiovascular disease diagnosis (e.g., MI, stroke, revascularization, TIA, unstable angina, amputation, or CAD)
• Documentation of concurrent type 2 diabetes mellitus diagnosis
• Prescriber attestation that agent is being used to reduce risk of major adverse cardiovascular events
• Confirmation that the agent is NOT being used for weight loss alone
• For new patients: attestation of no FDA labeled contraindications to Ozempic
• For new patients: attestation that agent will NOT be combined with another GLP-1 agonist
• For new patients: attestation that agent will NOT be combined with a DPP-4 inhibitor
• For continuation patients: evidence of current treatment (claim within past 180 days) OR prescriber attestation of current use within past 180 days

Approval and renewal

• Initial approval: 12 months
• Renewal: every 12 months

Not covered when

• Use for weight loss alone is excluded
• Combination use with another GLP-1 agonist or agent containing a GLP-1 agonist is excluded (for new patients)
• Combination use with a DPP-4 inhibitor is excluded (for new patients)

Policy note: CV risk reduction indication requires BOTH established CVD AND T2DM diagnosis simultaneously. T2DM is required (not excluded) for this indication under this policy. No GDMT requirement specified.

source: Capital BlueCross Medicare Advantage prior authorization policy · View policy document (PDF)

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Documentation of chronic kidney disease diagnosis
• Documentation of concurrent type 2 diabetes mellitus diagnosis
• Prescriber attestation that agent is being used to reduce risk of sustained eGFR decline, end-stage kidney disease, and cardiovascular death
• Confirmation that the agent is NOT being used for weight loss alone
• For new patients: attestation of no FDA labeled contraindications to Ozempic
• For new patients: attestation that agent will NOT be combined with another GLP-1 agonist
• For new patients: attestation that agent will NOT be combined with a DPP-4 inhibitor
• For continuation patients: evidence of current treatment (claim within past 180 days) OR prescriber attestation of current use within past 180 days

Approval and renewal

• Initial approval: 12 months
• Renewal: every 12 months

Not covered when

• Use for weight loss alone is excluded
• Combination use with another GLP-1 agonist or agent containing a GLP-1 agonist is excluded (for new patients)
• Combination use with a DPP-4 inhibitor is excluded (for new patients)

Policy note: CKD indication requires BOTH CKD AND T2DM diagnosis simultaneously. No specific eGFR or UACR thresholds are stated in this policy. Policy language references the FDA-approved CKD indication for Ozempic (risk reduction of sustained eGFR decline, ESKD, and CV death).

source: Capital BlueCross Medicare Advantage prior authorization policy · View policy document (PDF)