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 ≥ 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
- 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: 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 · View policy document (PDF)