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Fallon Health Plan

Does Fallon Health Plan cover Ozempic?

Yes. Fallon Health Plan covers Ozempic for type 2 diabetes with prior authorization. Other policy requirements and your plan's benefits also apply.

Policy document

  • Fallon Health Plan Medicaid prior authorization policy

    Fallon Health Plan · PA policy · Medicaid

    View PDF Download
  • Medicaid: Covered with requirements. See the qualification pathways below.

Earliest policy review May 25, 2026. How we verify · Check your exact plan

Full requirements: Ozempic for Type 2 Diabetes (1 plan type)

Applies to Medicaid plans.

Covered with requirements

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

  • Renewal: Improvement in A1C.
  • Renewal: 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: Fallon Health Plan Medicaid prior authorization policy · View policy document (PDF)

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Questions people ask
Does Fallon Health Plan cover Ozempic?
Yes. Fallon Health Plan covers Ozempic for type 2 diabetes with prior authorization. Other policy requirements and your plan's benefits also apply.
What does Fallon Health Plan require to renew Ozempic?
Type 2 Diabetes — Applies to Medicaid plans. Improvement in A1C. Documentation of reduction in A1C or a treatment plan to address reduction in A1C.
How current is this information?
The oldest review date among the policies on this page is May 25, 2026. Each policy's effective and verification dates appear with its requirements. Confirm current benefits with your plan.

Also under Fallon Health Plan: Wegovy

Ozempic under other plans: BCBS Massachusetts, Massachusetts Medicaid, Alabama Medicaid, Arkansas Medicaid, California Medicaid, Clover Health, Colorado Medicaid, Connecticut Medicaid

All insurance plans · All medications

Summary of Fallon Health Plan's written policy, not a guarantee of coverage. Plans vary by employer and benefit design.