Employer / Commercial Insurance
Covered (preferred drug)What you need to qualify
- Age 18 and older
- A1C of 6.5% or higher
- Trial of metformin for at least 90 days, or a documented reason it can't be used (["intolerance"])
Qualification pathways
You can qualify through any one of these.
Initial Approval - T2DM with metformin step therapy
All of:
- Diagnosis of type 2 diabetes mellitus confirmed by medical records (chart notes)
- Inadequate response or inability to tolerate a minimum 90-day supply of at least one metformin-containing generic (metformin, metformin ER, glipizide-metformin, glyburide-metformin, or pioglitazone-metformin)
Plus any one of:
- Ongoing treatment history for T2DM confirmed by chart notes (no lab required)
- A1c >= 6.5%
- Fasting plasma glucose >= 126 mg/dL
- 2-hour plasma glucose >= 200 mg/dL during OGTT
Documentation to bring
- Medical records (e.g., chart notes) confirming diagnosis of type 2 diabetes mellitus
- Lab result confirming T2DM (A1c >= 6.5%, FPG >= 126 mg/dL, or 2-hr PG >= 200 mg/dL during OGTT) OR documentation of ongoing treatment for T2DM
- Documentation of inadequate response or intolerance to minimum 90-day supply of at least one of: metformin, metformin ER, glipizide-metformin, glyburide-metformin, or pioglitazone-metformin
Approval and renewal
- Initial approval: 24 months
- Renewal: every 24 months
- To renew, the plan looks for improvement in A1C and Documentation of positive clinical response to therapy (e.g., reduction in A1c). Drug must not be solely used for weight loss.
Not covered when
- Drug approved only when not being used solely for weight loss (reauthorization requirement)
Policy note: Policy covers Ozempic under a single diabetes indication. CV risk reduction indication is not separately enumerated in this policy's criteria — the policy only describes T2DM glycemic control criteria for Ozempic/Rybelsus. The FDA-approved CV risk reduction indication is noted in the description but no separate PA pathway is defined. Reauthorization requires documentation that drug is not solely used for weight loss and documentation of positive clinical response (e.g., A1c reduction). Initial and reauthorization duration is 2 years.
source: Pa policy