Applies to ACA Marketplace plans.
Covered with requirementsQualification 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
- Renewal: 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 · View policy document (PDF)