Delaware Medicaid

Does Delaware Medicaid cover Ozempic?

Quick answer · Type 2 Diabetes

Delaware Medicaid covers Ozempic for type 2 diabetes with prior authorization on Medicaid.

  • Medicaid: Covered with requirements. Diagnosis documented with a code

Last verified June 4, 2026. Policy effective April 20, 2026. Source: Pa policy. How we verify this data →

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Ozempic for Type 2 Diabetes

What Delaware Medicaid requires, by plan type. Open this indication on its own page →

Medicaid

Covered with requirements

What you need to qualify

  • Diagnosis documented with a code

Qualification pathways

You can qualify through any one of these.

Initial approval for T2DM

All of:

  • Diagnosis of type 2 diabetes mellitus (T2DM) with ICD-10 code provided
  • FDA-approved indication for the requested GLP-1 agonist
  • Dosage, frequency, and age within FDA-approved range
  • No contraindicated conditions or diseases with GLP-1 agonist therapy
  • Member is not currently on another GLP-1 agonist

Non-preferred agent request

All of:

  • All initial approval criteria met
  • Preferred GLP-1 agents have been tried and results documented in medical records

Documentation to bring

  • Member's relevant medical records and/or pharmacy profile
  • Appropriate baseline diagnostic and safety laboratory and/or noninvasive test results
  • ICD-10 diagnosis code for T2DM
  • Pharmacy claims history or pharmacy profile
  • Documentation that dosage, frequency, and age are within FDA-approved range
  • Documentation that member has no contraindicated conditions/diseases with GLP-1 agonist therapy
  • Documentation that member is not currently on another GLP-1 agonist
  • If brand name is medically necessary: MedWatch Form 3500
  • If non-preferred agent: documentation that preferred medications have been utilized with results

Quantity limits

  • all strengths — ≤30-day supply (initial and dose-change re-authorization); ≤90-day supply (re-authorization with no dose change) (84-day)

Approval and renewal

  • Initial approval: 6 months
  • To renew, the plan looks for Provider must document reason for dose change (titrating) or no dose change (maintenance). Change in dose: approval up to 1 month in <=30-day supplies. No change in dose: approval up to 6 months in <=90-day supplies.

Not covered when

  • Contraindicated conditions or diseases with GLP-1 agonist therapy
  • Currently on another GLP-1 agonist
  • Off-label/unapproved indications without two peer-reviewed articles demonstrating safety and efficacy

Policy note: This is a Delaware Medicaid (DMAP) PA request form for GLP-1 agonists for T2DM. The policy is class-level (all GLP-1 agonists for T2DM) and does not specify individual brand criteria. Initial authorization is for a 6-month trial dispensed in ≤30-day supplies. Re-authorization: dose change = up to 1 month in ≤30-day supplies; no dose change = up to 6 months in ≤90-day supplies. Preferred vs. non-preferred distinction exists but specific preferred agents are not listed in this document. Brand name medical necessity requires MedWatch Form 3500.

Policy effective April 20, 2026 · verified June 4, 2026 · source: Pa policy

Ozempic for Heart Disease Risk Reduction

What Delaware Medicaid requires, by plan type. Open this indication on its own page →

Medicaid

Covered with requirements

What you need to qualify

  • BMI of 27 or higher
  • Diagnosis documented with a code
  • Established cardiovascular disease
  • Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Prevention of MACE

All of:

  • BMI >= 27 kg/m2
  • Established cardiovascular disease (CVD)

Documentation to bring

  • Member's relevant medical records and/or pharmacy profile
  • Appropriate baseline diagnostic and safety laboratory results with dates
  • Documentation of BMI >= 27 kg/m2
  • Documentation of established CVD
  • Documentation of reduced calorie diet
  • Documentation of increased physical activity
  • Confirmation that member is NOT currently on another GLP-1 agonist
  • Confirmation that member has no contraindicated conditions/medications with requested GLP-1
  • Pharmacy claims history or pharmacy profile

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 6 months
  • To renew, the plan looks for Prescriber must attest that the member continues to derive clinical benefit with the requested agent AND that the member requires ongoing therapy as part of the treatment plan. Resubmission of initial coverage documentation is NOT required at reauthorization.

Not covered when

  • Currently on another GLP-1 agonist
  • Has a contraindicated condition/disease with the requested GLP-1 agonist
  • Currently on a contraindicated medication with the requested GLP-1 agonist

Policy note: Policy refers to this indication as 'Prevention of Major Adverse Cardiovascular Events (MACE)'. Ozempic (semaglutide) is FDA-approved for CV risk reduction in T2DM patients with established CVD; the MACE criteria in this class-level policy require BMI >= 27 and established CVD. Initial authorization up to 6 months in <= 30-day supplies; reauthorization 6 months in <= 90-day supplies.

Policy effective April 20, 2026 · verified June 4, 2026 · source: Pa policy

Why Ozempic requests get denied by Delaware Medicaid

Based on what this policy asks for. Fix these before the first submission.

  1. Wrong brand for the diagnosis. Ozempic and Wegovy are the same molecule with different approved uses; a request for Ozempic under a diagnosis that matches Wegovy is routinely denied.
  2. Diagnosis code missing or wrong on the request.
  3. BMI not documented in the chart notes (or documented without a baseline weight and date).

Frequently asked questions

Does Delaware Medicaid cover Ozempic?
Delaware Medicaid covers Ozempic for type 2 diabetes with prior authorization on Medicaid.
How long does a Ozempic approval last with Delaware Medicaid?
Initial approvals last 6 months.
What does Delaware Medicaid require to renew Ozempic?
Provider must document reason for dose change (titrating) or no dose change (maintenance). Change in dose: approval up to 1 month in <=30-day supplies. No change in dose: approval up to 6 months in <=90-day supplies.
How current is this information?
This page reflects Delaware Medicaid's written policy as of April 20, 2026, last verified against the source document on June 4, 2026.

Other medications under Delaware Medicaid

Ozempic coverage under other plans

All insurance plans · All medications

This page summarizes Delaware Medicaid's written prior-authorization policy. It is not a guarantee of coverage; plans vary by employer and benefit design. Verify with your plan before relying on it.