Applies to Medicare Advantage plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
CV risk reduction with T2DM — new patient
All of:
- Patient has a diagnosis of established cardiovascular disease (e.g., MI, stroke, any revascularization procedure, TIA, unstable angina, amputation, symptomatic or asymptomatic CAD)
- Patient has a concurrent diagnosis of type 2 diabetes mellitus
- Requested agent will be used to reduce the risk of major adverse cardiovascular events (CV death, non-fatal MI, or non-fatal stroke)
- Patient does NOT have any FDA labeled contraindications to the requested agent
- Patient will NOT be using the requested agent in combination with another GLP-1 agonist or agent containing a GLP-1 agonist
- Patient will NOT be using the requested agent in combination with an agent containing a DPP-4 inhibitor
CV risk reduction with T2DM — continuation (currently on agent)
All of:
- Patient has a diagnosis of established cardiovascular disease with type 2 diabetes mellitus
- Requested agent will be used to reduce the risk of major adverse cardiovascular events
Plus any one of:
- Evidence of a claim that the patient is currently being treated with the requested agent within the past 180 days
- Prescriber states the patient is currently being treated with the requested agent within the past 180 days
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)