Fallon Health Plan

Does Fallon Health Plan cover Ozempic?

Quick answer ยท Type 2 Diabetes

Fallon Health Plan covers Ozempic for type 2 diabetes with prior authorization on Medicaid.

  • Medicaid: Covered with requirements. A1C of 5.7% or higher

Source: Pa policy. How we verify this data โ†’

Check your card for your exact plan โ†’

Ozempic for Type 2 Diabetes

What Fallon Health Plan requires, by plan type. Open this indication on its own page โ†’

Medicaid

Covered with requirements

What you need to qualify

  • A1C of 5.7% or higher
  • A1C no higher than 6.4%
  • Diagnosis documented with a code
  • Trial of metformin for at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication"])
  • Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Prediabetes with metformin failure/intolerance/contraindication

All of:

  • Diagnosis of prediabetes
  • Baseline A1c >= 5.7% and < 6.5%

Plus any one of:

  • Inadequate response to metformin at daily dose of 2000 mg/day
  • Adverse reaction to metformin
  • Contraindication to metformin at daily dose of 2000 mg/day

Documentation to bring

  • Diagnosis of prediabetes
  • Baseline A1c lab result (>= 5.7% and < 6.5%)
  • Documentation of inadequate response to metformin at 2000 mg/day, OR adverse reaction to metformin, OR contraindication to metformin at 2000 mg/day
  • For continuation: documentation of reduction in A1c or treatment plan to address A1c reduction

Approval and renewal

  • To renew, the plan looks for improvement in A1C and Documentation of reduction in A1c or a treatment plan to address reduction in A1c.

Policy note: Prediabetes criteria for Ozempic aligned with Mounjaro, Trulicity, Victoza as of February 17, 2026. Requires diagnosis, baseline A1c, and inadequate response, adverse reaction, or contraindication to metformin at 2000 mg/day. This is listed in the anti-diabetic guideline section. Note: The JSON schema uses 'indication' enum values; prediabetes does not have a dedicated enum value so it is captured under 'diabetes' with notes. The a1c_min/a1c_max reflect the prediabetes diagnostic range.

source: Pa policy

Why Ozempic requests get denied by Fallon Health Plan

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. No recent A1C result on file.
  4. No documented metformin trial (dose, dates, and outcome) or a stated reason it can't be used.

Frequently asked questions

Does Fallon Health Plan cover Ozempic?
Fallon Health Plan covers Ozempic for type 2 diabetes with prior authorization on Medicaid.
Do you have to try metformin before Ozempic?
Yes for type 2 diabetes: Fallon Health Plan requires a documented trial of metformin of at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication"]).
What does Fallon Health Plan require to renew Ozempic?
Improvement in A1C and Documentation of reduction in A1c or a treatment plan to address reduction in A1c.

Other medications under Fallon Health Plan

Ozempic coverage under other plans

All insurance plans · All medications

This page summarizes Fallon Health Plan'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.