Employer / Commercial Insurance
Covered (preferred drug)What you need to qualify
- Age 18 and older
- A1C of 6.5% or higher
- Trial of metformin for at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication", "ASCVD"])
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
Standard T2DM with metformin failure or contraindication
All of:
- Age >= 18 years
- Diagnosis of type 2 diabetes
- Lab-verified diagnosis: A1C >= 6.5% OR FPG >= 126 mg/dL OR 2-hr plasma glucose >= 200 mg/dL on OGTT OR symptoms of hyperglycemia/crisis with random glucose >= 200 mg/dL
Plus any one of:
- Trial and inadequate response or intolerance to metformin (samples/coupons/discount cards excluded)
- Contraindication to metformin therapy
- History of ASCVD (acute coronary syndrome, CAD, MI, stable/unstable angina, coronary or arterial revascularization, stroke, TIA, or PAD)
Documentation to bring
- Documentation of type 2 diabetes diagnosis
- Lab result confirming diagnosis: A1C >= 6.5%, OR fasting plasma glucose >= 126 mg/dL (after fasting >= 8 hours), OR 2-hour plasma glucose >= 200 mg/dL on 75g OGTT, OR random plasma glucose >= 200 mg/dL with symptoms of hyperglycemia/crisis
- Documentation of metformin trial with inadequate response or intolerance (samples/coupons/discount cards not accepted), OR documentation of metformin contraindication, OR documentation of ASCVD history
Quantity limits
- 0.25 mg/dose, 0.5 mg/dose — 1 prefilled pen (2 mg pen) per 28 days
- 1 mg/dose — 1 prefilled pen (4 mg pen) per 28 days
- 2 mg/dose — 1 prefilled pen (8 mg pen) per 28 days
- 1.5 mg tablet — 1 bottle (30 tablets) one-time fill
- 4 mg tablet, 9 mg tablet — 1 tablet per day
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- To renew, the plan looks for At continuation, the T2DM diagnosis and lab verification (A1C >= 6.5%, FPG >= 126 mg/dL, or equivalent) are re-verified. The metformin trial/contraindication/ASCVD bypass requirement is NOT re-checked at continuation.
Not covered when
- Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
- Personal or family history of medullary thyroid carcinoma (MTC)
- Severe gastroparesis
- Prediabetes
- Concomitant use with another GLP-1 receptor agonist (including Saxenda, Wegovy, Zepbound, Soliqua, or Xultophy)
- Concomitant use with a DPP-4 inhibitor (including Brynovin, Janumet/XR, Januvia, Jentadueto/XR, Kazano, Kombiglyze XR, Nesina, Onglyza, Oseni, Sitagliptin, Tradjenta, Zituvio, Zituvimet, Glyxambi, Qtern, Steglujan, or Trijardy XR)
- Type 1 diabetes
Policy note: Ozempic injection and Ozempic oral (tablet) share the same PA criteria. The ASCVD bypass to metformin step therapy is available for Ozempic. Quantity limits listed separately for injection and tablet formulations. Non-preferred agents (Bydureon BCise, Byetta, Victoza brand) require additional step through two preferred agents. Continuation criteria re-verify T2DM diagnosis and lab confirmation but do not re-require metformin trial/contraindication/ASCVD evidence.
Policy effective May 5, 2026 · verified June 2, 2026 · source: Download