Employer / Commercial Insurance
Covered with requirementsWhat you need to qualify
- Trial of metformin for at least 30 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.
Continuation/Post-step-therapy PA: A1C response
All of:
- Patient has been receiving Ozempic for at least 3 months
- Patient has demonstrated a reduction in A1C since starting therapy
Continuation/Post-step-therapy PA: Established cardiovascular disease
All of:
- Patient has established cardiovascular disease
Post-step PA (bypass metformin step): T2DM with metformin failure/intolerance
All of:
- Diagnosis of type 2 diabetes mellitus
Plus any one of:
- Inadequate treatment response to metformin
- Intolerance to metformin
- Contraindication to metformin
Post-step PA (bypass metformin step): T2DM requiring combination therapy
All of:
- Diagnosis of type 2 diabetes mellitus
- Patient requires combination therapy
- A1C >= 7.5%
Initial step therapy auto-pay: Prior metformin fill
All of:
- Patient has filled a prescription for at least a 30-day supply of metformin within the past 180 days under a CVS Caremark-administered prescription benefit
Documentation to bring
- Documentation of type 2 diabetes mellitus diagnosis
- Evidence of prior metformin fill (at least 30-day supply within past 180 days) OR documentation of inadequate response, intolerance, or contraindication to metformin
- A1C lab result demonstrating reduction since starting therapy (for continuation requests)
- Documentation of established cardiovascular disease (if qualifying via CV disease pathway)
- If requesting combination therapy pathway: A1C >= 7.5% and documentation that combination therapy is required
Approval and renewal
- To renew, the plan looks for improvement in A1C and Patient must have been receiving the requested drug for at least 3 months AND demonstrated a reduction in A1C since starting therapy. Alternatively, patient qualifies if they have established cardiovascular disease.
Not covered when
- Diabetic ketoacidosis
- History of pancreatitis (consider other antidiabetic therapies)
- Not recommended as first-line therapy for patients with inadequate glycemic control on diet and exercise alone
- Type 1 diabetes
Policy note: This is a step therapy policy (Policy 676-D, dated 07-2018). Initial step therapy for GLP-1 receptor agonists requires evidence of a prior metformin fill (at least 30-day supply within the past 180 days). If not met, a PA is required. The PA (post-step-therapy) coverage criteria require EITHER: (1) patient on drug >= 3 months with demonstrated A1C reduction, OR (2) established cardiovascular disease, OR (3) T2DM with metformin inadequate response/intolerance/contraindication, OR (4) T2DM requiring combination therapy with A1C >= 7.5%. The a1c_for_combination_therapy field is set to 7.5 reflecting the combination therapy pathway. The document does not separately address Ozempic for CV risk reduction or CKD as distinct indications; Ozempic's CV disease criterion here is framed as an alternative post-step coverage path for the diabetes indication. Policy references HMSA (Hawaii Medical Service Association) and CVS Caremark. Plan type cannot be determined with certainty. The effective date is inferred from the policy identifier '07-2018'; the full document date is stated as July 2018 — mapped to 2018-07-01. Wegovy, Mounjaro, and Zepbound are not mentioned in this document (predates their approval) and are not in documented_drugs.
Policy effective July 1, 2018 · verified June 5, 2026 · source: 14017_125606724