Centene coverage for Ozempic (Heart Disease Risk

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

Centene coverage for Ozempic (Heart Disease Risk Reduction)