Centene

Does Centene cover Ozempic?

Quick answer · Type 2 Diabetes

Centene covers Ozempic for type 2 diabetes with prior authorization on ACA Marketplace.

  • ACA Marketplace: Covered with requirements. Diagnosis documented with a code

Last verified June 2, 2026. Policy effective February 26, 2026. Source: CP.PMN.183.pdf. How we verify this data →

Check your card for your exact plan →

Ozempic for Type 2 Diabetes

What Centene requires, by plan type. Open this indication on its own page →

ACA Marketplace

Covered with requirements

What you need to qualify

  • Age 18 and older
  • Diagnosis documented with a code
  • Prior trial of 2 other GLP-1 medications (Victoza and Trulicity) for at least 90 days

Qualification pathways

You can qualify through any one of these.

T2DM with MASLD and overweight/obesity

All of:

  • Diagnosis of type 2 diabetes mellitus
  • Age >= 18 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 (2 mg/week)
  • 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 (CKD exception bypasses step therapy for Ozempic injection)

T2DM with MASH

All of:

  • Diagnosis of type 2 diabetes mellitus
  • Age >= 18 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 (2 mg/week)
  • 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 (CKD exception applies)

T2DM with ASCVD, high ASCVD risk, HFpEF, or CKD — agent with proven CV/renal benefit

All of:

  • Diagnosis of type 2 diabetes mellitus
  • Age >= 18 years
  • Ozempic (injection or tablets) is an agent with proven cardiovascular or renal benefit
  • Not prescribed concurrently with another GLP-1 receptor agonist or DPP-4 inhibitor
  • Dose does not exceed FDA-approved maximum (2 mg/week injection or 9 mg/day tablets)

Plus any one of:

  • Established atherosclerotic cardiovascular disease (ASCVD)
  • Indicators of high ASCVD risk (per Appendix D)
  • Heart failure with preserved ejection fraction
  • Chronic kidney disease — with failure of >= 3 consecutive months of SGLT2 inhibitor or SGLT2-containing product unless clinically significant adverse effects or all contraindicated; NOTE: for Ozempic injection in CKD, step therapy through liraglutide/Trulicity is bypassed

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 >= 18 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 (2 mg/week injection or 9 mg/day tablets)
  • Failure of both preferred GLP-1s: liraglutide (Victoza) for >= 3 consecutive months, then Trulicity for >= 3 consecutive months, unless clinically significant adverse effects or 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 (>= 18 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; note CKD bypass for Ozempic injection)
  • Documentation of failure of Trulicity for >= 3 consecutive months after Victoza failure (unless excepted; note CKD bypass for Ozempic injection)
  • 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
  • To renew, the plan looks for 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: Ozempic injection and Ozempic tablets (formerly Rybelsus R2 formulation, rebranded May 2026) are both covered for T2DM. Ozempic injection has a specific FDA indication for CKD — for CKD patients requesting Ozempic injection, the step therapy requirement through liraglutide (Victoza) and Trulicity is bypassed. Ozempic injection dosing note: for patients with T2DM and CKD, dose should be increased to maintenance dose of 1 mg once weekly after at least 4 weeks on 0.5 mg. Ozempic tablets (formerly Rybelsus R2) are not substitutable mg-per-mg with Ozempic injection. This policy covers both Ozempic injection and Ozempic tablets as non-preferred agents requiring step therapy except where CKD bypass applies.

Policy effective February 26, 2026 · verified June 2, 2026 · source: CP.PMN.183.pdf

Ozempic for Heart Disease Risk Reduction

What Centene requires, by plan type. Open this indication on its own page →

ACA Marketplace

Covered with requirements

What you need to qualify

  • Age 18 and older
  • Diagnosis documented with a code
  • Prior trial of 2 other GLP-1 medications (Victoza and Trulicity) for at least 90 days
  • Established cardiovascular disease (established_ASCVD and high_ASCVD_risk)

Qualification pathways

You can qualify through any one of these.

CV risk reduction in T2DM — established ASCVD or high ASCVD risk

All of:

  • Diagnosis of type 2 diabetes mellitus
  • Age >= 18 years
  • Ozempic injection is FDA-approved for CV risk reduction in T2DM with established CVD; Ozempic tablets are approved for patients at high risk for major adverse CV events
  • Failure of >= 3 consecutive months of SGLT2 inhibitor or SGLT2-containing product 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
  • Failure of both preferred GLP-1s: liraglutide (Victoza) for >= 3 consecutive months, then Trulicity for >= 3 consecutive months (unless excepted)

Plus any one of:

  • Established atherosclerotic cardiovascular disease (ASCVD)
  • Indicators of high ASCVD risk (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

Documentation to bring

  • Office chart notes or other clinical documentation of type 2 diabetes mellitus diagnosis
  • Documentation of established ASCVD, high ASCVD risk indicators, HFpEF, or CKD
  • Documentation of failure or contraindication/adverse effects for SGLT2 inhibitor trial >= 3 months
  • Documentation of failure of liraglutide (Victoza) >= 3 months (unless excepted)
  • Documentation of failure of Trulicity >= 3 months (unless excepted)
  • Confirmation of no concurrent GLP-1 receptor agonist or DPP-4 inhibitor use

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • To renew, the plan looks for Member is responding positively to therapy. 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: CV risk reduction for Ozempic is covered under the same T2DM criteria framework, specifically pathway I.A.3.d. Both Ozempic injection (established CVD) and Ozempic tablets (high CV risk) have FDA-approved CV indications. Coverage requires underlying T2DM diagnosis — this is not a standalone CV indication without diabetes. The policy does not separate CV risk reduction from diabetes management; both are handled under the T2DM approval pathway.

Policy effective February 26, 2026 · verified June 2, 2026 · source: CP.PMN.183.pdf

Ozempic for Kidney Disease (CKD)

What Centene requires, by plan type. Open this indication on its own page →

ACA Marketplace

Covered with requirements

What you need to qualify

  • Age 18 and older
  • Diagnosis documented with a code

Qualification pathways

You can qualify through any one of these.

T2DM with CKD — Ozempic injection only (step therapy bypassed)

All of:

  • Diagnosis of type 2 diabetes mellitus
  • Age >= 18 years
  • Diagnosis of chronic kidney disease
  • Request is for Ozempic injection (the only GLP-1 with FDA-approved CKD indication)
  • Failure of >= 3 consecutive months of SGLT2 inhibitor or SGLT2-containing product 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 (2 mg/week)
  • Step therapy through liraglutide (Victoza) and Trulicity is BYPASSED for Ozempic injection in members with CKD

Documentation to bring

  • Office chart notes or clinical documentation of type 2 diabetes mellitus diagnosis
  • Documentation of chronic kidney disease diagnosis
  • Documentation of failure or contraindication/adverse effects for SGLT2 inhibitor trial >= 3 months
  • Confirmation of no concurrent GLP-1 receptor agonist or DPP-4 inhibitor use
  • Ozempic injection specified (not Ozempic tablets) — only injection has FDA-approved CKD indication

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • To renew, the plan looks for Member is responding positively to therapy. 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: Ozempic injection is the ONLY GLP-1 receptor agonist with an FDA-approved indication for CKD (to reduce risk of sustained eGFR decline, ESKD, and CV death in adults with T2DM and CKD). When requesting Ozempic injection for CKD, the step therapy requirement through liraglutide (Victoza) and Trulicity is explicitly bypassed per criterion I.A.4.d. Dosing for CKD patients: increase to maintenance dose of 1 mg once weekly after at least 4 weeks on 0.5 mg.

Policy effective February 26, 2026 · verified June 2, 2026 · source: CP.PMN.183.pdf

Why Ozempic requests get denied by Centene

Based on what this policy asks for. Fix these before the first submission.

  1. Wrong brand for the diagnosis. Ozempic and Wegovy are the same molecule with different approved uses; a request for Ozempic under a diagnosis that matches Wegovy is routinely denied.
  2. Diagnosis code missing or wrong on the request.
  3. Required prior medication trials not documented.

Frequently asked questions

Does Centene cover Ozempic?
Centene covers Ozempic for type 2 diabetes with prior authorization on ACA Marketplace.
How long does a Ozempic approval last with Centene?
Initial approvals last 12 months, and renewals are granted in 12-month periods.
What does Centene require to renew Ozempic?
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.
How current is this information?
This page reflects Centene's written policy as of February 26, 2026, last verified against the source document on June 2, 2026.

Other medications under Centene

Ozempic coverage under other plans

All insurance plans · All medications

This page summarizes Centene's written prior-authorization policy. It is not a guarantee of coverage; plans vary by employer and benefit design. Verify with your plan before relying on it.