Medicaid
Covered (preferred drug)What you need to qualify
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
Initial approval for type 2 diabetes
All of:
- Appropriate diagnosis of type 2 diabetes
- Baseline A1C dated within 90 days prior to initiation
- Requested agent will not be used in combination with another GLP-1 receptor agonist
- If requested quantity exceeds quantity limits, clinical rationale provided
SmartPA for type 2 diabetes (no PA request needed)
All of:
- Claims within quantity limit
- Member has history of medical claims for type 2 diabetes mellitus OR history of medical claims for prediabetes with history of paid claims for at least 84 days of GLP-1/GIP/GLP-1 agonist therapy within the last 120-day period
Documentation to bring
- Appropriate diagnosis of type 2 diabetes
- Baseline A1C lab result dated within 90 days prior to initiation
- Attestation that requested agent will not be used in combination with another GLP-1 receptor agonist
- If quantity exceeds limits: clinical rationale why dose cannot be consolidated or for exceeding FDA-approved dosing
- For recertification: current A1C dated within last 90 days
- For recertification: evidence of A1C reduction, A1C ≤ 7%, or treatment plan for A1C escalation
Quantity limits
- all strengths — 1 prefilled pen per 28-day supply
Approval and renewal
- To renew, the plan looks for improvement in A1C and Current A1C within last 90 days required. Must show: reduction in A1C since initiation, OR A1C ≤ 7% (dated within last 90 days), OR treatment plan addressing escalation of therapy for A1C reduction.
Not covered when
- Combination use with another GLP-1 receptor agonist is prohibited unless transitioning (with discontinuation of prior GLP-1)
Policy note: Ozempic is a Preferred Drug (PD) in the MassHealth formulary for type 2 diabetes. No step therapy through lower-potency GLP-1s is required for initial approval for T2DM (unlike Bydureon/Rybelsus which require prior failure of high-potency GLP-1s including Ozempic). SmartPA pathway allows claims to process without PA request if member has T2DM claims history and GLP-1 claims history meeting criteria. Prediabetes indication is also covered under a separate pathway (see notes for liraglutide/Mounjaro/Ozempic/Trulicity section) requiring metformin trial or exception plus step through liraglutide (Victoza) and Trulicity before Ozempic is approved for prediabetes.
verified June 4, 2026 · source: policy-348.html