Employer / Commercial Insurance
Covered (preferred drug)No additional clinical requirements are listed beyond the diagnosis.
Qualification pathways
You can qualify through any one of these.
Initial approval for Type 2 Diabetes
All of:
- Diagnosis of Type 2 Diabetes Mellitus
Documentation to bring
- Documentation of Type 2 Diabetes Mellitus diagnosis
- Progress notes documenting previous treatments and treatment history
- Laboratory test results as applicable
- Documentation supporting medical necessity of requested product
Quantity limits
- 0.25mg, 0.5mg, 1mg, 2mg — 1 pen (3 mL); 3 pens (9 mL) (84-day)
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- To renew, the plan looks for Clinical documentation must be submitted at recertification supporting continued medical necessity; ongoing use must reflect current formulary. Recertification may require trial of more cost-effective alternatives (generics, biosimilars, or other guideline-supported options) as they become available.
Policy note: Ozempic Pen and Ozempic Tablet (semaglutide oral) are listed as preferred agents requiring only a T2DM diagnosis. Rybelsus is also semaglutide oral (same generic as Ozempic Tablet). Quantity limit for Ozempic Pen: 1 pen (3 mL) per 28 days. Collective GLP-1/GIP agonist quantity limits apply cumulatively across all products regardless of indication: maximum 14 fills of 28/30-day supply per rolling 365 days OR maximum 5 fills of 84/90-day supply per rolling 365 days. Only one GLP-1/GIP product at one strength may be approved per 28/30-day period. Weight loss and cardiovascular indications are handled under a separate policy (PHARMACY-03). New York State insurance law stepwise-therapy override provisions apply.
Policy effective January 1, 2024 · verified June 5, 2026 · source: diabetic-incretin-mimetic-agents-policy-pdf