Employer / Commercial Insurance
Covered with requirements
What you need to qualify
Qualification pathways
You can qualify through any one of these.
Type 2 Diabetes Mellitus – age-based approval (injection and tablets)
All of:
- Diagnosis of type 2 diabetes mellitus
- Patient is >= 18 years of age
Documentation to bring
- Documentation of type 2 diabetes mellitus diagnosis
- Patient age >= 18 years
Approval and renewal
- Initial approval: 12 months
Not covered when
- Weight loss without type 2 diabetes diagnosis
- Prediabetes/diabetes prevention
- Metabolic syndrome without type 2 diabetes
- Concomitant use with other GLP-1 agonists or GLP-1/GIP agonists
- Type 1 diabetes
Policy note: Covers both Ozempic subcutaneous injection and Ozempic tablets (semaglutide tablets; formerly Rybelsus 1.5 mg, 4 mg, 9 mg rebranded as of January 30, 2026). Automation exists for Ozempic tablets added effective 05/06/2026. Policy also notes Ozempic has labeled CV risk reduction and CKD indications but this policy only addresses the diabetes indication; those indications are not separately covered under this diabetes-specific PA policy.
Policy effective May 6, 2026 · verified June 2, 2026 · source: cnf_360_coveragepositioncriteria_glucagon-like_peptide-1_agonists_pa.pdf
Medicare Part D
Covered with requirements
No additional clinical requirements are listed beyond the diagnosis.
Qualification pathways
You can qualify through any one of these.
All FDA-approved indications with diagnosis
All of:
- Diagnosis documented
- FDA-approved indication
Documentation to bring
Approval and renewal
- Initial approval: 12 months
Policy note: Policy allows all FDA-approved indications with no prerequisite therapy required. Only required medical information is a diagnosis. No prescriber restrictions, no age restrictions, no exclusion criteria listed. Authorization duration is 1 year. No Part B prerequisite. Document lists Ozempic with specific strengths: 0.25 mg or 0.5 mg (2 MG/3 ML), 1 MG/DOSE (4 MG/3 ML), 2 MG/DOSE (8 MG/3 ML).
Policy effective July 1, 2026 · verified June 11, 2026 · source: prior-authorization-crosswalked.pdf
Medicare Advantage
Covered with requirements
No additional clinical requirements are listed beyond the diagnosis.
Qualification pathways
You can qualify through any one of these.
All FDA-approved indications with diagnosis
All of:
- Diagnosis documented
- FDA-approved indication
Documentation to bring
Approval and renewal
- Initial approval: 12 months
Policy note: Policy allows all FDA-approved indications with no prerequisite therapy required. Only required medical information is a diagnosis. No prescriber restrictions, no age restrictions, no exclusion criteria listed. Authorization duration is 1 year. No Part B prerequisite. Document lists Ozempic with specific strengths: 0.25 mg or 0.5 mg (2 MG/3 ML), 1 MG/DOSE (4 MG/3 ML), 2 MG/DOSE (8 MG/3 ML).
Policy effective July 1, 2026 · verified June 11, 2026 · source: prior-authorization-crosswalked.pdf
ACA Marketplace
Covered with requirements
What you need to qualify
Qualification pathways
You can qualify through any one of these.
Type 2 Diabetes Mellitus – age-based approval (injection and tablets)
All of:
- Diagnosis of type 2 diabetes mellitus
- Patient is >= 18 years of age
Documentation to bring
- Documentation of type 2 diabetes mellitus diagnosis
- Patient age >= 18 years
Approval and renewal
- Initial approval: 12 months
Not covered when
- Weight loss without type 2 diabetes diagnosis
- Prediabetes/diabetes prevention
- Metabolic syndrome without type 2 diabetes
- Concomitant use with other GLP-1 agonists or GLP-1/GIP agonists
- Type 1 diabetes
Policy note: Covers both Ozempic subcutaneous injection and Ozempic tablets (semaglutide tablets; formerly Rybelsus 1.5 mg, 4 mg, 9 mg rebranded as of January 30, 2026). Automation exists for Ozempic tablets added effective 05/06/2026. Policy also notes Ozempic has labeled CV risk reduction and CKD indications but this policy only addresses the diabetes indication; those indications are not separately covered under this diabetes-specific PA policy.
Policy effective May 6, 2026 · verified June 2, 2026 · source: cnf_360_coveragepositioncriteria_glucagon-like_peptide-1_agonists_pa.pdf
