Medicaid
Covered (preferred drug)What you need to qualify
- Age 18 and older
- Trial of metformin for at least 90 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.
Type 2 Diabetes (with or without CVD and/or CKD)
All of:
- Member is 18 years of age or older
- Diagnosis of type 2 diabetes mellitus confirmed by chart documentation or claims history
- Baseline HbA1c submitted, obtained within past 90 days (lab documentation required)
- Member is not on concomitant DPP-4 inhibitor-containing agent OR is transitioning from DPP-4 inhibitor (45-day transition permitted)
- Member will not use concurrently with another GLP-1 RA or combination product
- Dose does not exceed 2 mg/week
Plus any one of:
- Previous trial of metformin for at least 90 days within past 120 days (confirmed by claims, chart, or provider attestation including dates)
- Documented intolerance or contraindication to metformin therapy
Documentation to bring
- Chart documentation or claims history confirming T2DM diagnosis
- Baseline HbA1c lab result obtained within past 90 days
- Claims history, chart documentation, or provider attestation of metformin trial >=90 days within past 120 days (including dates of trial), OR documentation of metformin intolerance/contraindication
- Documentation confirming no concomitant DPP-4 inhibitor use (or 45-day transition plan)
Approval and renewal
- Initial approval: 6 months
- Renewal: every 12 months
- To renew, the plan looks for improvement in A1C, HbA1c reduction from baseline OR trend toward stabilization over past year. If neither demonstrated, prescriber must submit medical justification with chart note support. HbA1c must be obtained within past 90 days (if on therapy <1 year) or within past 180 days (if on therapy >=1 year). Must have history of requested agent for at least 84 days within past 112 days, and at least 12 weeks on therapy before the first renewal.
Not covered when
- No concurrent use with another GLP-1 RA or combination product
- No concurrent DPP-4 inhibitor (45-day transition permitted)
- Dose must not exceed 2 mg/week
Policy note: Preferred agent. Metformin trial must be within the past 120 days (not just any prior trial). Ozempic is also used as a preferred step-therapy prerequisite for non-preferred agents. At reauthorization, the 84-day history requirement uses a 112-day lookback window.
Policy effective July 1, 2026 · verified June 4, 2026 · source: 20260701_Public-Facing_GLP-1%20RA-GIP-Combinations_PA_Final.pdf