Medicaid
Covered (preferred drug)What you need to qualify
- Diagnosis documented with a code
- Trial of metformin for at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication", "ASCVD"])
Qualification pathways
You can qualify through any one of these.
Preferred Agent: Type 2 Diabetes with Metformin Trial
All of:
- Diagnosis of Type II diabetes
Plus any one of:
- Trial and failure of metformin
- Intolerance to metformin
Preferred Agent: Type 2 Diabetes with ASCVD (no metformin trial required)
All of:
- Diagnosis of Type II diabetes
- Diagnosis of ASCVD associated with Type II diabetes
Documentation to bring
- Documentation of Type II diabetes diagnosis
- Documentation of metformin trial and failure or intolerance, OR documentation of ASCVD associated with Type II diabetes
Policy note: Ozempic appears on BOTH the Preferred and Non-Preferred lists. As a preferred agent, it requires T2DM diagnosis plus metformin trial/failure/intolerance, OR T2DM with ASCVD (no metformin trial required). The document also lists Ozempic as a non-preferred agent with notation 'AL, NR, QTAB' — this likely refers to a specific formulation (tablet/oral form, i.e., Rybelsus-like oral semaglutide) or a second listing; the non-preferred criteria require failure of TWO preferred GLP-1 RA agents, HbA1C ≥ 7, and metformin trial or contraindication/intolerance. The preferred injectable Ozempic (semaglutide) pen is captured here. Age limit (AL) and quantity limit (QL) are noted but specific values are not detailed in this document excerpt. The document includes an 'AL' flag indicating an age limit applies, but the specific age threshold is not stated in the provided text.
Policy effective June 1, 2026 · verified June 4, 2026 · source: NE_PDL-20260601.pdf