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Kaiser Permanente Mid-Atlantic

Does Kaiser Permanente Mid-Atlantic cover Ozempic for Type 2 Diabetes?

Yes. Kaiser Permanente Mid-Atlantic covers Ozempic for type 2 diabetes with prior authorization. Other policy requirements and your plan's benefits also apply.

Policy document

  • Hmo Exchange Prior Authorization Criteria En

    Kaiser Permanente Mid-Atlantic · PA policy · Employer, ACA Marketplace, and Federal Employee Program

    Effective June 2, 2026. Verified June 5, 2026.

    View PDF Download Original insurer source
  • Employer, ACA Marketplace, and Federal Employee Program: Covered (preferred drug). See the qualification pathways below.

Earliest policy review June 5, 2026. How we verify · Check your exact plan

Full requirements: Ozempic for Type 2 Diabetes (3 plan types)

Applies to Employer, ACA Marketplace, and Federal Employee Program plans.

Covered (preferred drug)

Qualification pathways

You can qualify through any one of these.

Initial approval for type 2 diabetes (Ozempic as preferred GLP-1)

All of:

  • Diagnosis of type 2 diabetes mellitus
  • Most recent HbA1c obtained within 3 months of PA request
  • Patient is NOT on another GLP-1 agonist or any DPP-4 inhibitor
  • Failed adequate trial (adherence/MRAR ≥80% for at least 3 months) of metformin at maximum tolerated dose unless intolerance or contraindication
  • Failed adequate trial (adherence/MRAR ≥80% for at least 3 months) of an SGLT2 inhibitor (generic dapagliflozin preferred) at maximum tolerated dose unless intolerance or contraindication

Plus any one of:

  • HbA1c is within 2% ABOVE goal (per ADA guidelines)
  • HbA1c is ≥2% ABOVE goal AND patient is optimized on concomitant insulin therapy (insulin glargine-yfgn preferred)

Documentation to bring

  • Diagnosis of type 2 diabetes mellitus
  • Most recent HbA1c lab result obtained within 3 months of PA request
  • Documentation of adequate trial (≥3 months, adherence/MRAR ≥80%) of metformin at maximum tolerated dose, OR documentation of intolerance or contraindication to metformin
  • Documentation of adequate trial (≥3 months, adherence/MRAR ≥80%) of an SGLT2 inhibitor (generic dapagliflozin preferred) at maximum tolerated dose, OR documentation of intolerance or contraindication
  • Documentation that patient is not currently on another GLP-1 agonist or DPP-4 inhibitor
  • If HbA1c ≥2% above goal with concomitant insulin: documentation that insulin regimen has been titrated to max tolerated dose or documentation of intolerance to insulin

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 6 months
  • Renewal: Improvement in A1C.
  • Renewal: If no diagnosis of ASCVD or indicators of high ASCVD risk, patient must meet ONE of: achieved goal A1C, documented A1C lowering of 1% from initial baseline prior to starting GLP-1, OR documented A1C lowering of 0.5% from time of last review. ASCVD requirement and step therapy are not re-verified at continuation for existing members who have previously met criteria.

Not covered when

  • Patient currently on another GLP-1 agonist
  • Patient currently on a DPP-4 inhibitor
  • Type 1 diabetes

Policy note: Ozempic is the preferred GLP-1 agonist in this formulary. Other GLP-1 agents (Trulicity, Bydureon, Rybelsus, Mounjaro, brand Victoza) require documented trial, intolerance, or contraindication to Ozempic in addition to meeting the base class criteria. For continuation: new members initiated outside KPMAS must confirm all initial review criteria are met. For existing members, if patient has ASCVD or indicators of high ASCVD risk, A1C requirements for continuation do not apply. Liraglutide (AG of Victoza) is listed as a step-therapy prerequisite within the class criteria but is subject to its own PA; it is the preferred generic/authorized generic GLP-1 within the class step therapy. The document references non-DM indications for GLP-1 RAs as being covered under separate Wegovy, Saxenda, or Zepbound criteria (not established in this document).

Policy effective June 2, 2026 · verified June 5, 2026 · source: Hmo Exchange Prior Authorization Criteria En · View policy document (PDF)

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Questions people ask
Does Kaiser Permanente Mid-Atlantic cover Ozempic?
Yes. Kaiser Permanente Mid-Atlantic covers Ozempic for type 2 diabetes with prior authorization. Other policy requirements and your plan's benefits also apply.
How long does a Ozempic approval last with Kaiser Permanente Mid-Atlantic?
Type 2 Diabetes — Applies to Employer, ACA Marketplace, and Federal Employee Program plans. Initial approval: 6 months. Renewal: every 6 months.
What does Kaiser Permanente Mid-Atlantic require to renew Ozempic?
Type 2 Diabetes — Applies to Employer, ACA Marketplace, and Federal Employee Program plans. Improvement in A1C. If no diagnosis of ASCVD or indicators of high ASCVD risk, patient must meet ONE of: achieved goal A1C, documented A1C lowering of 1% from initial baseline prior to starting GLP-1, OR documented A1C lowering of 0.5% from time of last review. ASCVD requirement and step therapy are not re-verified at continuation for existing members who have previously met criteria.
How current is this information?
The oldest review date among the policies on this page is June 5, 2026. Each policy's effective and verification dates appear with its requirements. Confirm current benefits with your plan.

Also under Kaiser Permanente Mid-Atlantic: Mounjaro, Wegovy, Zepbound

Ozempic under other plans: Elevance Health, Alabama Medicaid, Arkansas Medicaid, California Medicaid, Clover Health, Colorado Medicaid, Connecticut Medicaid, Delaware Medicaid

All insurance plans · All medications

Summary of Kaiser Permanente Mid-Atlantic's written policy, not a guarantee of coverage. Plans vary by employer and benefit design.