Medicaid
Covered with requirementsWhat you need to qualify
- Age 18 and older
- A1C of 7% or higher
- Diagnosis documented with a code
- Prior trial of another GLP-1 medication (exenatide and Victoza)
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
T2DM on background antidiabetic therapy with prior GLP-1 failure
All of:
- Age >= 18 years
- Diagnosis of type 2 diabetes mellitus
- HbA1c >= 7%
- Currently on metformin, SGLT2 inhibitor, sulfonylurea, or thiazolidinedione therapy
- Inadequate response, allergy, contraindication, drug-drug interaction, or intolerable side effects to exenatide AND Victoza
T2DM with CKD with prior preferred SGLT2 and GLP-1 failure
All of:
- Age >= 18 years
- Diagnosis of type 2 diabetes mellitus
- Chronic kidney disease (CKD)
- HbA1c >= 7%
- Inadequate response, allergy, contraindication, drug-drug interaction, or intolerable side effects to metformin AND SGLT2 inhibitor (Farxiga, Xigduo XR, or Jardiance)
T2DM with established cardiovascular disease with prior GLP-1 failure
All of:
- Age >= 18 years
- Diagnosis of type 2 diabetes mellitus
- HbA1c >= 7%
- Established cardiovascular disease (history of coronary artery disease, stroke, cerebrovascular disease, or peripheral artery disease)
- Inadequate response, allergy, contraindication, drug-drug interaction, or intolerable side effect with Victoza
Documentation to bring
- Documentation of type 2 diabetes mellitus diagnosis
- HbA1c lab result >= 7%
- For standard pathway: documentation of current background antidiabetic therapy (metformin, SGLT2 inhibitor, sulfonylurea, or thiazolidinedione)
- Documentation of inadequate response, allergy, contraindication, drug-drug interaction, or intolerable side effects to exenatide
- Documentation of inadequate response, allergy, contraindication, drug-drug interaction, or intolerable side effects to Victoza
- For CKD pathway: documentation of CKD diagnosis and failure of metformin and an SGLT2 inhibitor (Farxiga, Xigduo XR, or Jardiance)
- For CVD pathway: documentation of established cardiovascular disease (coronary artery disease, stroke, cerebrovascular disease, or peripheral artery disease)
Policy note: Ozempic is listed as non-preferred under Miscellaneous Antidiabetic Agents. Three separate qualifying pathways exist: (1) standard T2DM on background therapy with exenatide and Victoza failure; (2) T2DM with CKD requiring metformin and SGLT2 inhibitor failure; (3) T2DM with established CVD requiring only Victoza failure. Ozempic itself is named as a required prior failure step for Mounjaro and Trulicity. Quantity level limits are referenced externally.
Policy effective December 8, 2025 · verified June 4, 2026 · source: download