Delaware Medicaid coverage for Ozempic (Heart Disease Risk Reduction)

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.

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