EmblemHealth coverage for Ozempic (Type 2 Diabetes)

What you need to qualify

• Age 18 and older

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Confirmation of type 2 diabetes mellitus diagnosis
• Documentation of patient age >= 18 years

Approval and renewal

• Initial approval: 12 months

Not covered when

• Weight loss without type 2 diabetes diagnosis
• Prediabetes/diabetes prevention without type 2 diabetes diagnosis
• Metabolic syndrome without type 2 diabetes diagnosis
• Concomitant use with another GLP-1 agonist or GLP-1/GIP agonist
• Type 1 diabetes

Policy note: Automation rule: If patient has had a prior oral diabetes medication (not Rybelsus or single-entity metformin) in the past 130 days at point of service AND is >= 18 years old, may bypass PA. Otherwise PA criteria apply. Policy explicitly states Wegovy (semaglutide for weight loss) is NOT targeted in this policy. Off-label use for weight loss without T2DM is not recommended for approval.

source: Pa policy