Employer / Commercial Insurance
Covered (preferred drug)
What you need to qualify
- 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.
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
- To renew, the plan looks for improvement in A1C and 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.pdf
ACA Marketplace
Covered (preferred drug)
What you need to qualify
- 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.
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
- To renew, the plan looks for improvement in A1C and 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.pdf
Federal Employee Program
Covered (preferred drug)
What you need to qualify
- 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.
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
- To renew, the plan looks for improvement in A1C and 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.pdf
