Fallon Health Plan coverage for Ozempic (Type 2 Diabetes)

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.

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