Ohio Medicaid coverage for Ozempic (Type 2

Medicaid

Covered with requirements

What you need to qualify

Diagnosis documented with a code
Prior trial of another GLP-1 medication (BYETTA, exenatide, VICTOZA, liraglutide, and TRULICITY) for at least 120 days
Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Initial Approval - Step Therapy with 3 preferred drugs

All of:

Diagnosis of Type 2 Diabetes Mellitus (T2DM)
Current A1C documented within the last 6 months
Prescriber has listed patient's goal A1C value
Patient has tried THREE preferred medications titrated to maximum treatment doses for 120 days and was unable to reach A1C goal
One of the three preferred drugs must be a preferred GLP-1 receptor agonist (BYETTA, exenatide, VICTOZA, liraglutide, or TRULICITY)
The preferred GLP-1 medication was used concurrently with at least one other preferred non-insulin medication in the Endocrine Agents: Diabetes - Non-Insulin UPDL category for 120 days
Patient had documented adherence with medications
Doses were titrated to maximum treatment dose for 120 days

Initial Approval - GI Intolerance Exception to preferred GLP-1 trial

All of:

Diagnosis of Type 2 Diabetes Mellitus (T2DM)
Current A1C documented within the last 6 months
Prescriber has listed patient's goal A1C value
Patient was unable to complete 120 days of preferred GLP-1 due to gastrointestinal (GI) intolerance
Chart documentation submitted that dietary changes were tried for at least 30 days
Chart documentation submitted that prescription antiemetics were tried for at least 30 days
Chart documentation submitted that dose adjustment was tried for at least 30 days to remediate side effects

Documentation to bring

ICD-10 diagnosis code for Type 2 Diabetes Mellitus (T2DM)
Current A1C lab result within the last 6 months
Prescriber-documented goal A1C value with justification if more stringent than <7%
Documentation of three preferred medications titrated to maximum doses for 120 days with names, doses, and dates of use
Documentation that one preferred GLP-1 agonist (BYETTA, exenatide, VICTOZA, liraglutide, or TRULICITY) was used concurrently with at least one other preferred non-insulin medication
Documentation of patient adherence with trial medications
If maximum doses were not reached or GI intolerance prevented completion: chart documentation of dietary changes, prescription antiemetics, and dose adjustment each tried for at least 30 days

Approval and renewal

Renewal: every 12 months
To renew, the plan looks for improvement in A1C and Patient must show improvement in A1C from baseline when the requested medication was started. Current A1C (within last 6 months) and baseline A1C must be submitted. Prescriber must also attest patient is being monitored for safety and efficacy. Prior authorization approval from Gainwell within the last year must be documented. Patient must have received medication under ODM benefit (not samples) within the last 365 days.

Not covered when

Requests for conditions other than T2DM will not be approved per FDA approved labeling
Obesity treatment is explicitly not covered under Ohio Medicaid per OAC 5160-9-03
EPSDT exception available for patients under age 21 via Standard PA Fillable Form
Type 1 diabetes

Policy note: This is a non-preferred drug on the Ohio Unified Preferred Drug List (UPDL). The document indicates that Wegovy for non-obesity indications and Zepbound for OSA have separate PA request forms at https://spbm.medicaid.ohio.gov/. Drugs used for the treatment of obesity are explicitly not covered by Ohio Medicaid per OAC 5160-9-03. Renewal requests require completion of Section A and Section D only. A1C lab results must be within the last 6 months for both initial and renewal requests. The form revision date is 04/01/2026.

Policy effective April 1, 2026 · verified June 4, 2026 · source: Pa policy

Ohio Medicaid coverage for Ozempic (Type 2 Diabetes)