Applies to Medicaid plans.
Covered (preferred drug)Qualification pathways
You can qualify through any one of these.
Initial approval — preferred agent (Ozempic injection) for T2DM
All of:
- Appropriate diagnosis code on prescription
- Documented diagnosis of type 2 diabetes mellitus confirmed by: A1C ≥6.5%, OR fasting plasma glucose ≥126 mg/dL, OR 2-hour plasma glucose ≥200 mg/dL during OGTT, OR classic hyperglycemia symptoms with random plasma glucose ≥200 mg/dL
- Provider attests GLP-1 receptor agonist will be used alongside diet and exercise
- Prescribed medication will not be used with another GLP-1 receptor agonist
- Patient does not have personal or family history of medullary thyroid carcinoma (MTC) or multiple endocrine neoplasia syndrome type 2 (MEN 2)
- Patient is not on concomitant DPP-4 inhibitor therapy OR provider attests patient is transitioning from a DPP-4 inhibitor to a GLP-1 receptor agonist
Documentation to bring
- Appropriate diagnosis code on prescription
- Chart note or laboratory results documenting T2DM diagnosis (A1C ≥6.5%, fasting glucose ≥126 mg/dL, 2-hour OGTT glucose ≥200 mg/dL, or classic hyperglycemia symptoms with random glucose ≥200 mg/dL)
- Provider attestation that GLP-1 will be used alongside diet and exercise
- Provider attestation that prescribed medication will not be used with another GLP-1 receptor agonist
- For continuation: baseline AND recent (within 180 days of submission) A1C/glycemic lab values with dates
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- Renewal: Improvement in A1C.
- Renewal: Documented improvement in hemoglobin A1C; submission of baseline AND recent (within 180 days) lab values with dates documenting improvement in glycemic control or maintenance of glycemic goal required. Patient must not be on concomitant DPP-4 inhibitor therapy. T2DM diagnosis must still be documented.
Not covered when
- Personal or family history of medullary thyroid carcinoma (MTC)
- Personal or family history of multiple endocrine neoplasia syndrome type 2 (MEN 2)
- Concomitant use of another GLP-1 receptor agonist containing product
- Concomitant DPP-4 inhibitor use (unless transitioning)
Policy note: Ozempic (semaglutide) injection is a PREFERRED agent; no step therapy or prior GLP-1 trial required for initial approval — only T2DM diagnosis confirmation and appropriate diagnosis code. Ozempic tablets (oral semaglutide) are a separate non-preferred listing with age minimum of 18 years — see Rybelsus entry for those criteria (both are listed under the same non-preferred category as 'Ozempic tablets'). The injection formulation has no stated minimum age in this document. Document notes Ozempic tablets were added to the criteria document in V3 (4/29/2026). Gastrointestinal side effects are noted as expected class effects and not considered intolerance unless medical justification for discontinuation is provided. Use of samples to initiate therapy does not meet step therapy requirements.
Policy effective January 1, 2026 · verified June 3, 2026 · source: GLP-1 · View policy document (PDF)