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.
Initial approval — Preferred agent (Ozempic)
All of:
- Diagnosis of type 2 diabetes
- Diagnosis confirmed by lab tests (e.g., A1C >= 6.5%); lab test results or medical records required
- Patient age is within FDA labeling for the requested indication, OR there is support for using the requested agent for the patient's age for the requested indication
- Patient will NOT use the requested agent in combination with a DPP-4 inhibitor
- Patient will NOT use the requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications to the requested agent
Continuation of therapy
All of:
- Diagnosis of type 2 diabetes
- Diagnosis confirmed by lab tests (e.g., A1C >= 6.5%); lab test results or medical records required
- Patient will NOT use the requested agent in combination with a DPP-4 inhibitor
- Patient will NOT use the requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications to the requested agent
Plus any one of:
- Patient has been treated with a preferred agent within the past 90 days (starting on samples is not approvable)
- Prescriber attests patient has been treated with a preferred agent within the past 90 days (starting on samples not approvable) AND patient is at risk if therapy with a preferred agent is discontinued
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
- To renew, the plan looks for 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: Pa policy