How long does a Ozempic approval last with Medical Mutual?

Initial approvals last 6 months, and renewals are granted in 12-month periods.

Does Medical Mutual cover Ozempic?

Ozempic for Type 2 Diabetes

What Medical Mutual requires, by plan type. Open this indication on its own page →

Employer / Commercial Insurance

Covered (preferred drug)

What you need to qualify

Age 18 and older
A1C of 6.5% or higher
Diagnosis documented with a code (E11)
Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Type 2 Diabetes - Initial Approval

All of:

Patient is >= 18 years of age
Diagnosis of type 2 diabetes confirmed by lab values

Plus any one of:

HbA1c >= 6.5%
Fasting plasma glucose >= 126 mg/dL
2-hour plasma glucose >= 200 mg/dL

Automation Pathway - Non-Preferred Step Therapy Bypass

All of:

ICD-10 code starting with E11.*
History of metformin use (alone or in combination) within previous 130 days OR claims for oral antidiabetic medications (excluding single-agent metformin) within last 365 days AND history of metformin use within previous 130 days
Patient is >= 18 years of age

Documentation to bring

Diagnosis of type 2 diabetes (ICD-10 E11.*)
Lab confirmation of T2DM: HbA1c >= 6.5%, OR fasting plasma glucose >= 126 mg/dL, OR 2-hour plasma glucose >= 200 mg/dL
Documentation of patient age >= 18 years

Approval and renewal

Initial approval: 6 months
Renewal: every 12 months

Not covered when

Weight loss without type 2 diabetes diagnosis
Prediabetes/diabetes prevention without confirmed T2DM
PCOS without type 2 diabetes
Metabolic syndrome without type 2 diabetes
Concomitant use with other GLP-1 agonists or GLP-1/GIP agonists
Type 1 diabetes

Policy note: Automation criteria allow approval without manual review when ICD-10 E11.* codes are present AND metformin history within 130 days (or other oral antidiabetics within 365 days plus metformin within 130 days) is documented. For non-preferred medications, a history of one preferred medication within the 130-day look-back period is also required for automation. Step therapy requires trial of a preferred medication before non-preferred agents. The policy explicitly states that weight loss use (without T2DM) is NOT covered under this policy; Wegovy and Saxenda are separate products not included in this policy.

source: Pa policy

Why Ozempic requests get denied by Medical Mutual

Based on what this policy asks for. Fix these before the first submission.

Wrong brand for the diagnosis. Ozempic and Wegovy are the same molecule with different approved uses; a request for Ozempic under a diagnosis that matches Wegovy is routinely denied.
Diagnosis code missing or wrong on the request.
No recent A1C result on file.

Frequently asked questions

Does Medical Mutual cover Ozempic?: Medical Mutual covers Ozempic for type 2 diabetes with prior authorization on Employer / Commercial Insurance.
How long does a Ozempic approval last with Medical Mutual?: Initial approvals last 6 months, and renewals are granted in 12-month periods.