Employer / Commercial Insurance
Covered (preferred drug)What you need to qualify
- A1C of 6.5% or higher
- Trial of metformin for at least 90 days, or a documented reason it can't be used (["contraindication", "ASCVD", "heart_failure", "CKD"])
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
New Start — Preferred Agent (Ozempic)
All of:
- Diagnosis of type 2 diabetes
- A1C >= 6.5% confirmed by lab test
- Patient will NOT use the requested agent in combination with a DPP-4 containing agent
- Patient will NOT use the requested agent in combination with another GLP-1 receptor agonist
- Patient will NOT use the requested agent in combination with OTC weight management products or supplements that may increase GLP hormone
- Patient does NOT have any FDA labeled contraindications to the requested agent
- Patient age is within FDA labeling for the requested indication
Plus any one of:
- Medication history of use in the past 90 days to an agent containing metformin or insulin
- FDA labeled contraindication to BOTH metformin AND insulin
- Diagnosis of type 2 diabetes with or at high risk for atherosclerotic cardiovascular disease, heart failure, and/or chronic kidney disease
Continuation of Therapy — Preferred Agent (Ozempic)
All of:
- Diagnosis of type 2 diabetes
- A1C >= 6.5% confirmed by lab test
- Patient will NOT use the requested agent in combination with a DPP-4 containing agent
- Patient will NOT use the requested agent in combination with another GLP-1 receptor agonist
- Patient will NOT use the requested agent in combination with OTC weight management products or supplements that may increase GLP hormone
- Patient does NOT have any FDA labeled contraindications to the requested agent
- Patient age is within FDA labeling for the requested indication
Plus any one of:
- Patient has been treated with a preferred agent within the past 90 days (starting on samples is not approvable)
- Prescriber states patient has been treated with a preferred agent within the past 90 days and patient is at risk if therapy with a preferred agent is discontinued
Documentation to bring
- Documentation of type 2 diabetes diagnosis
- Lab result confirming A1C >= 6.5%
- Documentation of prior metformin or insulin use within past 90 days, OR documentation of FDA labeled contraindication to both metformin AND insulin, OR documentation of T2DM with/at high risk for ASCVD, heart failure, and/or CKD
- Attestation that patient will not use requested agent in combination with a DPP-4 inhibitor
- Attestation that patient will not use requested agent in combination with another GLP-1 receptor agonist
- Attestation that patient will not use requested agent in combination with OTC weight management products or GLP-hormone-increasing supplements
- Confirmation patient has no FDA labeled contraindications to the requested agent
Quantity limits
- 2 MG/3ML, 4 MG/3ML, 8 MG/3ML — 1 pen per 28 days
- 1.5 MG tablet, 4 MG tablet, 9 MG tablet — 30 tablets per 30 days
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- To renew, the plan looks for Continuation eligible if patient has been treated with a preferred agent within the past 90 days (samples not approvable), or prescriber attests patient has been treated with a preferred agent within past 90 days and is at risk if therapy is discontinued.
Not covered when
- Concurrent use with DPP-4 containing agents
- Concurrent use with another GLP-1 receptor agonist
- Concurrent use with OTC weight management products (e.g., orlistat/Alli) or supplements that may increase GLP hormone (e.g., berberine, curcumin, taurine, ginseng, wild bitter gourd)
- FDA labeled contraindications to the requested agent (personal or family history of MTC or MEN 2; prior serious hypersensitivity reaction)
Policy note: Fill limit of one GLP-1 agent and one strength per 28 days. Ozempic injection is a preferred agent; Ozempic tablets (Rybelsus) share semaglutide tablet quantity limits. The policy covers Ozempic for its FDA-labeled T2DM indication including glycemic control, CV risk reduction in T2DM with established CVD, and CKD risk reduction in T2DM — all under the same PA criteria for type 2 diabetes. The CV and CKD indications listed in the FDA label table are subsumed within T2DM criteria here; no separate CV/CKD pathway with distinct criteria is established in this document. QL approval is up to 12 months; one-time approval for titration dose extensions or when replacing another GLP-1 agent/strength within QL but over fill limit.
Policy effective May 11, 2026 · verified June 5, 2026 · source: NJ_GLP-1_Agonists_PAQL_ProgSum.pdf