Applies to Employer and ACA Marketplace plans.
Covered (preferred drug)Qualification pathways
You can qualify through any one of these.
Initial Approval – Preferred Agent (Ozempic/semaglutide 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
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
Quantity limits
- 2 MG/3ML — 1 pen per 28 days
- 4 MG/3ML — 1 pen per 28 days
- 8 MG/3ML — 1 pen per 28 days
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- Renewal: 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, Mounjaro, 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
- 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: Ozempic (semaglutide injectable) is listed as a PREFERRED agent. Rybelsus (oral semaglutide) shares the same clinical criteria and is also covered under this policy. Quantity limit: fill limit of one injectable GLP-1 agent and one strength per 28 days; refill window applies. Oral semaglutide (Rybelsus) subject to fill limit of one oral GLP-1 agent and one strength per 28 days. When a non-preferred agent requests approval, Ozempic/Rybelsus serves as one of the preferred step therapy agents that must have been tried. BCBSOK approval is 36 months.
Policy effective May 11, 2026 · verified June 2, 2026 · source: Hcsc GLP-1 Agonists Prog Sum · View policy document (PDF)