Medicaid
Covered (preferred drug)What you need to qualify
- A1C no higher than 7%
- Prescribed by or in consultation with a specialist
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
Initial approval for non-preferred GLP-1 (Ozempic is PREFERRED - no PA required)
All of:
- Ozempic (semaglutide) is a PREFERRED agent under GLP-1 Agonists section - NO PA required for initial use
- Non-preferred GLP-1 agents (Trulicity, liraglutide) require: member has been unable to achieve goal A1C (≤7%) or TIR (>70%) despite a 90-day trial of triple combination therapy consisting of Ozempic (for Trulicity, liraglutide must be trialed if semaglutide including Rybelsus is not tolerated), along with metformin, SGLT-2 inhibitor or insulin
Plus any one of:
- Requested medication prescribed by or in consult with an endocrinologist or diabetes specialist
- Member has received diabetes education from a diabetic specialist, diabetic educator, or pharmacist (may be accomplished through the MTM program)
Documentation to bring
- Evidence of inability to achieve goal A1C (≤7%) or TIR (>70%) despite 90-day trial of triple combination therapy (Ozempic + metformin + SGLT-2 inhibitor or insulin), evidenced by paid claims or pharmacy printouts
- Prescriber attestation of consultation with endocrinologist or diabetes specialist, OR documentation of diabetes education from diabetic specialist, educator, or pharmacist
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- To renew, the plan looks for Member must have experienced and maintained clinical benefit since starting treatment; must continue to meet initial criteria; must be at least 80% adherent to medication (or provide clinical justification for non-adherence with a plan to improve).
Not covered when
- DPP-4 inhibitors and GLP-1 agonists are not payable together (therapeutic duplication)
- GI intolerances typically will not be considered to bypass trial requirements (specific mitigation steps required first)
Policy note: Ozempic (semaglutide) is a PREFERRED GLP-1 agent for diabetes - NO PA required. Non-preferred GLP-1 agents (Trulicity/dulaglutide, liraglutide/Victoza) require PA after failure of triple therapy including Ozempic. For GI intolerance to Ozempic: chart documentation must be submitted showing dietary changes, reduction in meal size, prescription antiemetics, and dose adjustment were trialed for at least two months before bypassing. Rybelsus (semaglutide oral) is also a preferred GLP-1 agent per PDL (no PA required). Note: The document states 'Ozempic and Victoza (brand) are covered without prior authorization by submitting diagnosis code T43.505A, T43.505D, or T43.505S if being used for antipsychotic-induced weight gain' under Weight Loss section.
Policy effective April 1, 2026 · verified June 3, 2026 · source: PDL-2026.4.pdf