Applies to Medicaid plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
Preferred agent: Type 2 Diabetes (GLP-1 RA class)
All of:
- Request adheres to all FDA approved labeling for requested drug and indication, including age, dosing, contraindications, warnings and precautions, drug interactions, and use in specific populations
- Diagnosis of Type 2 Diabetes Mellitus
- Current A1C value provided
- Combination use with a DPP-4 inhibitor-containing agent is not requested
Non-preferred agent: Type 2 Diabetes (GLP-1 RA class) — if Ozempic is non-preferred
All of:
- Request adheres to all FDA approved labeling for requested drug and indication, including age, dosing, contraindications, warnings and precautions, drug interactions, and use in specific populations
- Diagnosis of Type 2 Diabetes Mellitus
- Current A1C value provided
- Combination use with a DPP-4 inhibitor-containing agent is not requested
- Documentation of previous trials and therapy failures with a preferred drug in the same class
- Documentation of previous trials and therapy failures with at least 3 preferred agents from 3 different drug classes at maximally tolerated doses
Documentation to bring
- Current A1C lab result
- Documentation of FDA-approved indication and adherence to labeling (age, dosing, contraindications, warnings, drug interactions)
- If non-preferred: documentation of previous trials and therapy failures with preferred drug in the same class, including dates, dose, and nature of failure
- If non-preferred: documentation of previous trials and therapy failures with at least 3 preferred agents from 3 different drug classes at maximally tolerated doses, including dates, dose, and nature of failure
Not covered when
- Combination with DPP-4 inhibitor-containing agent will not be considered
- Pharmaceutical samples will not be considered when evaluating prior prescription history
- Duplicate use of drugs from the same therapeutic category will not be considered
Policy note: The document establishes PA criteria under the 'Anti-Diabetics, Non-Insulin Agents' section. GLP-1 receptor agonists are covered for Type 2 Diabetes Mellitus. Ozempic is included as a GLP-1 RA in this drug class per rule 27a class expansion. The policy explicitly states that weight loss is not a covered diagnosis; only the diabetes indication is covered. If Ozempic is a preferred agent, only the general criteria (criteria 1-3) apply. If non-preferred, criteria 4 (step therapy with 3 preferred agents from 3 different classes) also applies. Required trials must be at appropriate dose and duration and documented with dates, dose, and nature of failure. Trials may be overridden with documentation that use would be medically contraindicated.
Policy effective June 1, 2026 · verified June 4, 2026 · source: Policy 387