Kansas Medicaid coverage for Ozempic (Heart Disease

Medicaid

Covered with requirements

What you need to qualify

Age 18 and older
Established cardiovascular disease (coronary_heart_disease, cerebrovascular_disease, stroke, TIA, PAD, MI, unstable_angina, arterial_revascularization, and CABG)

Qualification pathways

You can qualify through any one of these.

Risk reduction of major CV events with T2DM and established CV disease

All of:

Diagnosis of T2DM
Age >= 18 years
Dose does not exceed 2 mg SQ once weekly
Patient is not currently on a DPP-4 inhibitor
Preferred PDL drug trial completed unless non-preferred PDL PA criteria met

Plus any one of:

History of coronary heart disease
History of cerebrovascular disease (stroke or TIA)
History of peripheral arterial disease
History of acute coronary syndrome (MI or unstable angina)
History of arterial revascularization (e.g., CABG)

High risk of developing ASCVD (alternative to established ASCVD)

All of:

Diagnosis of T2DM
Age >= 18 years
Dose does not exceed 2 mg SQ once weekly
Patient is not currently on a DPP-4 inhibitor
Preferred PDL drug trial completed unless non-preferred PDL PA criteria met

Plus any one of:

Age >= 55 years with coronary, carotid, or lower extremity artery stenosis >50%
Left ventricular hypertrophy (LVH)
10-year ASCVD risk >= 15%
Diagnosis of heart failure
Diagnosis of chronic kidney disease

Documentation to bring

Diagnosis of T2DM
Documentation of established ASCVD (coronary heart disease, cerebrovascular disease, PAD, ACS, or arterial revascularization) OR qualifying high-risk criteria (age >=55 with >50% stenosis, LVH, 10-year ASCVD risk >=15%, CKD, or heart failure)
Confirmation patient is not currently on a DPP-4 inhibitor
Documentation that preferred PDL drug was tried or reason for non-preferred PA criteria

Quantity limits

0.25mg, 0.5mg, 1mg, 2mg — Max 2 mg SQ once weekly

Approval and renewal

To renew, the plan looks for No renewal required for CV risk reduction indication (indefinite initial approval).

Not covered when

Concurrent DPP-4 inhibitor use
Type 1 diabetes

Policy note: Approval for CV risk reduction is indefinite (no renewal required) per the policy. T2DM is required for this CV indication (this is the Ozempic SUSTAIN-6/CVOT indication requiring established T2DM with CV disease, not the Wegovy non-diabetic CV indication). The document groups CV and CKD indications together under 'risk reduction in related comorbidities' with the same qualifying criteria.

Policy effective April 16, 2025 · verified June 4, 2026 · source: Diabetes-Mellitus-Type-2-Agents-PDF

Kansas Medicaid coverage for Ozempic (Heart Disease Risk Reduction)