Applies to ACA Marketplace plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
T2DM with MASLD and overweight/obesity
All of:
- Diagnosis of type 2 diabetes mellitus
- Age ≥ 10 years
- Diagnosis of MASLD
- BMI 25-29.9 kg/m2 (overweight) or BMI ≥ 30 kg/m2 (obese)
- Not prescribed concurrently with another GLP-1 receptor agonist or DPP-4 inhibitor
- Dose does not exceed FDA-approved maximum (15 mg/week for adults, 10 mg/week for pediatrics)
- Failure of both preferred GLP-1s: liraglutide (Victoza) for ≥ 3 consecutive months, then Trulicity for ≥ 3 consecutive months, unless clinically significant adverse effects, both contraindicated, or member has CKD and request is for Ozempic injection
T2DM with MASH
All of:
- Diagnosis of type 2 diabetes mellitus
- Age ≥ 10 years
- Diagnosis of MASH
- Failure of ≥ 3 consecutive month trial of pioglitazone unless contraindicated or clinically significant adverse effects
- Not prescribed concurrently with another GLP-1 receptor agonist or DPP-4 inhibitor
- Dose does not exceed FDA-approved maximum (15 mg/week for adults, 10 mg/week for pediatrics)
- Failure of both preferred GLP-1s: liraglutide (Victoza) for ≥ 3 consecutive months, then Trulicity for ≥ 3 consecutive months, unless clinically significant adverse effects, both contraindicated, or member has CKD and request is for Ozempic injection
T2DM with ASCVD, high ASCVD risk, HFpEF, or CKD — agent with proven CV/renal benefit
All of:
- Diagnosis of type 2 diabetes mellitus
- Age ≥ 10 years
- Mounjaro is an agent with proven cardiovascular benefit per 2026 ADA guidelines
- Not prescribed concurrently with another GLP-1 receptor agonist or DPP-4 inhibitor
- Dose does not exceed FDA-approved maximum (15 mg/week for adults, 10 mg/week for pediatrics)
- Failure of both preferred GLP-1s: liraglutide (Victoza) for ≥ 3 consecutive months, then Trulicity for ≥ 3 consecutive months, unless clinically significant adverse effects, both contraindicated, or member has CKD and request is for Ozempic injection
Plus any one of:
- Established atherosclerotic cardiovascular disease (ASCVD)
- Indicators of high ASCVD risk (per Appendix D: age ≥ 55 with coronary/carotid/lower-extremity artery stenosis >50%, LVH, retinopathy, other end organ damage)
- Heart failure with preserved ejection fraction
- Chronic kidney disease
- Failure of ≥ 3 consecutive months of SGLT2 inhibitor or SGLT2 inhibitor-containing product, unless clinically significant adverse effects or all contraindicated
T2DM without ASCVD, high ASCVD risk, HFpEF, CKD, MASLD, or MASH — non-GLP-1 step therapy
All of:
- Diagnosis of type 2 diabetes mellitus
- Age ≥ 10 years
- No established ASCVD, indicators of high ASCVD risk, heart failure with preserved ejection fraction, CKD, MASLD, or MASH
- Failure of ≥ 3 consecutive month trial of two agents from any of the following classes: biguanides, sulfonylureas, thiazolidinediones, DPP-4 inhibitors, SGLT2 inhibitors or SGLT2 inhibitor-containing products, unless clinically significant adverse effects or all contraindicated
- Not prescribed concurrently with another GLP-1 receptor agonist or DPP-4 inhibitor
- Dose does not exceed FDA-approved maximum (15 mg/week for adults, 10 mg/week for pediatrics)
- Failure of both preferred GLP-1s: liraglutide (Victoza) for ≥ 3 consecutive months, then Trulicity for ≥ 3 consecutive months, unless clinically significant adverse effects, both contraindicated
Documentation to bring
- Office chart notes, lab results, or other clinical information supporting all approval criteria
- Documentation of type 2 diabetes mellitus diagnosis
- Documentation of member age (≥ 10 years)
- Documentation of qualifying condition pathway (MASLD with overweight/obesity, MASH with pioglitazone trial/failure, ASCVD/high ASCVD risk/HFpEF/CKD with SGLT2i trial/failure, or two non-GLP-1 agent trial/failures)
- Documentation of failure of liraglutide (Victoza) for ≥ 3 consecutive months (unless excepted)
- Documentation of failure of Trulicity for ≥ 3 consecutive months after Victoza failure (unless excepted)
- Confirmation that requested product is not prescribed concurrently with another GLP-1 receptor agonist or DPP-4 inhibitor
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- Renewal: Member is responding positively to therapy. Continued therapy requires either (a) currently receiving medication via Centene benefit or previously met initial approval criteria, or (b) enrolled in a state with continuity of care regulations. No concurrent use with another GLP-1 or DPP-4 inhibitor.
Not covered when
- Concurrent use with another GLP-1 receptor agonist
- Concurrent use with a DPP-4 inhibitor
- Dose exceeding FDA-approved maximum recommended dose
- Type 1 diabetes
Policy note: Mounjaro is classified as a non-preferred GLP-1 receptor agonist requiring step therapy through liraglutide (Victoza) then Trulicity. Per 2026 ADA guidelines, Mounjaro was added as an agent with proven cardiovascular benefit. Age expansion to ≥ 10 years added per 2026 annual review. Mounjaro is a dual GLP-1/GIP receptor agonist but categorized under GLP-1 class policy. Pediatric maximum dose is 10 mg/week; adult maximum dose is 15 mg/week.
Policy effective February 26, 2026 · verified June 2, 2026 · source: Cp.Pmn.183 · View policy document (PDF)