Employer / Commercial Insurance
Covered (preferred drug)What you need to qualify
- A1C of 6.5% or higher
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
Initial Approval – Preferred Agent (Mounjaro is preferred)
All of:
- Diagnosis of type 2 diabetes
- Diagnosis confirmed by lab: A1C >= 6.5%, OR fasting plasma glucose >= 126 mg/dL, OR 2-hour plasma glucose >= 200 mg/dL during OGTT, OR random plasma glucose >= 200 mg/dL with symptoms of hyperglycemia
- Patient will NOT use requested agent in combination with a DPP-4 containing agent
- Patient will NOT use requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications to the requested agent
- Patient age is within FDA labeling for the requested indication OR there is support for use at patient's age
Plus any one of:
- Request is for a BCBS IL Fully Insured, ASO Cost/BBF, HIM, or Non-ERISA ASO/Self-insured Municipalities/Counties member
- Prescriber states patient is currently stable on the requested agent
- Requested agent is a preferred GLP-1 or GLP-1/GIP receptor agonist
Initial Approval – Non-Preferred Agent Step Therapy (if Mounjaro is requested as non-preferred)
All of:
- Diagnosis of type 2 diabetes
- Diagnosis confirmed by lab: A1C >= 6.5%, OR fasting plasma glucose >= 126 mg/dL, OR 2-hour plasma glucose >= 200 mg/dL during OGTT, OR random plasma glucose >= 200 mg/dL with symptoms of hyperglycemia
- Patient will NOT use requested agent in combination with a DPP-4 containing agent
- Patient will NOT use requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications to the requested agent
- Patient age is within FDA labeling for the requested indication OR there is support for use at patient's age
- TWO of the following step therapy groups must be satisfied (one from group 1 re: semaglutide AND one from group 2 re: dulaglutide, OR other combinations per policy)
Plus any one of:
- Tried and had inadequate response to semaglutide (Ozempic or Rybelsus)
- Semaglutide discontinued due to lack of efficacy, diminished effect, or adverse event
- Intolerance or hypersensitivity to semaglutide
- FDA labeled contraindication to semaglutide
- Semaglutide expected to be ineffective, cause barrier to adherence, worsen comorbidity, decrease functional ability, cause adverse reaction, or cause physical/mental harm
- Semaglutide not in best interest of patient based on medical necessity
- Tried another drug in same class as semaglutide, discontinued due to lack of efficacy or adverse event
- Requested agent is medically necessary and appropriate for the patient (re: semaglutide step)
- Tried and had inadequate response to dulaglutide (Trulicity)
- Dulaglutide discontinued due to lack of efficacy, diminished effect, or adverse event
- Intolerance or hypersensitivity to dulaglutide
- FDA labeled contraindication to dulaglutide
- Dulaglutide expected to be ineffective, cause barrier to adherence, worsen comorbidity, decrease functional ability, cause adverse reaction, or cause physical/mental harm
- Dulaglutide not in best interest of patient based on medical necessity
- Tried another drug in same class as dulaglutide, discontinued due to lack of efficacy or adverse event
- Requested agent is medically necessary and appropriate for the patient (re: dulaglutide step)
Alternative Approval – BCBS NM Fully Insured or NM HIM Rare Disease
All of:
- Request is for a BCBS NM Fully Insured or NM HIM member
- Patient does NOT have any FDA labeled contraindications to the requested agent
- Requested indication is a rare disease
Plus any one of:
- Patient has another FDA labeled indication for the requested agent and route of administration
- Patient has another indication supported in compendia for the requested agent and route of administration
Alternative Approval – Ohio Fully Insured or HIM Shop (SG)
All of:
- Member resides in Ohio
- Plan is Fully Insured or HIM Shop (SG)
- Patient does NOT have any FDA labeled contraindications to the requested agent
Plus any one of:
- Patient has another FDA labeled indication for the requested agent and route of administration
- Patient has another indication supported in compendia for the requested agent and route of administration
- Prescriber has submitted TWO articles from major peer-reviewed professional medical journals supporting the proposed use as generally safe and effective
Documentation to bring
- Chart notes or copy of lab test results confirming T2DM diagnosis (A1C >= 6.5%, fasting plasma glucose >= 126 mg/dL, 2-hour plasma glucose >= 200 mg/dL during OGTT, or random plasma glucose >= 200 mg/dL with symptoms)
- Documentation that patient will not use requested agent with a DPP-4 containing agent
- Documentation that patient will not use requested agent with another GLP-1 receptor agonist
- Documentation of absence of FDA labeled contraindications
- For non-preferred agents: documentation of step therapy trials/failures/intolerances/contraindications for two preferred agents (semaglutide and dulaglutide or tirzepatide as applicable)
Quantity limits
- 2.5 MG/0.5ML — 4 pens per 28 days (180-day duration for starter pack)
- 5 MG/0.5ML, 7.5 MG/0.5ML, 10 MG/0.5ML, 12.5 MG/0.5ML, 15 MG/0.5ML — 4 pens per 28 days
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- To renew, the plan looks for Patient must have demonstrated clinical benefit with a targeted GLP-1 agent. Prior A1C/lab confirmation and step therapy requirements are NOT re-verified at renewal; only clinical benefit, preferred/non-preferred step therapy status, no DPP-4 combination, no dual GLP-1, and no contraindications are checked.
Not covered when
- Concurrent use with DPP-4 containing agents (e.g., Januvia, Onglyza, Tradjenta, Nesina, and combination products)
- Concurrent use with another GLP-1 receptor agonist (e.g., Saxenda, Wegovy, Zepbound, Ozempic, etc.)
- FDA labeled contraindications to the requested agent
Exceptions
- Ohio: Ohio Fully Insured or HIM Shop (SG) members may qualify under Ohio alternative pathway
- BCBSIL: Approval duration 12 months; BCBS IL Fully Insured, ASO Cost/BBF, HIM, or Non-ERISA ASO/Self-insured Municipalities/Counties members may qualify without standard step therapy; starter pack and maintenance product each approved for 12 months if separate GPI-14
- BCBSOK: Approval duration 36 months (initial and renewal)
- BCBS_NM: NM Fully Insured or NM HIM members may qualify under rare disease alternative pathway
Policy note: Mounjaro is listed as a PREFERRED agent on this formulary. The policy covers GLP-1 and GLP-1/GIP receptor agonists for type 2 diabetes only. Quantity limit: fill limit of one injectable GLP-1 agent and one strength per 28 days; refill window applies. For 2.5 mg starter dose used for maintenance therapy (inability to use FDA-labeled maintenance strength), both inability to use maintenance strength AND clinical benefit from lower dose must be documented. BCBSOK approval is 36 months for both initial and renewal.
Policy effective May 11, 2026 · verified June 2, 2026 · source: HCSC_GLP-1_Agonists_ProgSum.pdf