Medicaid
Covered (preferred drug)No additional clinical requirements are listed beyond the diagnosis.
Qualification pathways
You can qualify through any one of these.
GLP-1 Special PA for T2DM — stabilized on requested product
All of:
- FDA approved diagnosis of type 2 diabetes mellitus
- Member is currently stabilized on the requested product (documentation must be provided)
GLP-1 Special PA for T2DM — cannot use lower-tiered GLP-1/GIP-GLP-1 agonists
All of:
- FDA approved diagnosis of type 2 diabetes mellitus
- Patient-specific, clinically significant reason (other than convenience) why member cannot use all available lower-tiered GLP-1 or GIP/GLP-1 agonists
Documentation to bring
- Documentation of FDA approved type 2 diabetes mellitus diagnosis
- Documentation that member is currently stabilized on the requested product OR patient-specific, clinically significant reason why member cannot use all available lower-tiered GLP-1 or GIP/GLP-1 agonists
Policy note: Ozempic (semaglutide injection) appears in the GIP/GLP-1 Agonists table as a Tier-2 brand-preferred product. The Special PA criteria for GLP-1 Agonists and GIP/GLP-1 Agonists apply when Ozempic is the subject of the PA request. A clinical exception applies for medications with a unique FDA approved indication not covered by all Tier-2 and Tier-3 GLP-1 or GIP/GLP-1 agonists. Tier-2 antidiabetic approval criteria also underlie the GLP-1 tier structure: T2DM diagnosis required plus at least 3-month metformin trial (unless intolerable) or clinically significant reason metformin is not appropriate. No quantity limits are specified in this document for Ozempic specifically.
verified June 4, 2026 · source: policy-385.html