Applies to Employer plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
Initial Approval - Metformin Trial/Failure
All of:
- Member is 18 years of age or older
- Diagnosis of type 2 diabetes mellitus confirmed by at least one of: fasting glucose >126 mg/dL, 2-hour glucose tolerance test >200 mg/dL, HbA1c ≥6.5%, or symptoms of hyperglycemia plus random plasma glucose ≥200 mg/dL (abnormal results confirmed on second occasion unless unequivocal)
- Unable to use OR has adequately tried and failed metformin at minimum dose of 1500 mg daily for 90 days
Initial Approval - Combination Therapy with High A1C
All of:
- Member is 18 years of age or older
- Diagnosis of type 2 diabetes mellitus confirmed by at least one of: fasting glucose >126 mg/dL, 2-hour glucose tolerance test >200 mg/dL, HbA1c ≥6.5%, or symptoms of hyperglycemia plus random plasma glucose ≥200 mg/dL (abnormal results confirmed on second occasion unless unequivocal)
- Requires combination therapy
- A1C ≥ 7.5%
Initial Approval - Established Cardiovascular Disease
All of:
- Member is 18 years of age or older
- Diagnosis of type 2 diabetes mellitus confirmed by at least one of: fasting glucose >126 mg/dL, 2-hour glucose tolerance test >200 mg/dL, HbA1c ≥6.5%, or symptoms of hyperglycemia plus random plasma glucose ≥200 mg/dL (abnormal results confirmed on second occasion unless unequivocal)
- Has established cardiovascular disease
Continuation - A1C Improvement
All of:
- Member has been receiving Ozempic for at least 3 months
- Has demonstrated a reduction in A1C since starting therapy
Continuation - Established Cardiovascular Disease
All of:
- Member has been receiving Ozempic for at least 3 months
- Has established cardiovascular disease
Documentation to bring
- Documentation confirming type 2 diabetes diagnosis (fasting glucose >126 mg/dL, 2-hour GTT >200 mg/dL, HbA1c ≥6.5%, or symptoms plus random plasma glucose ≥200 mg/dL; confirmed on second occasion unless unequivocal)
- Documentation of metformin trial at minimum 1500 mg/day for 90 days with inadequate response, OR documentation of metformin intolerance/contraindication, OR documentation of combination therapy need with A1C ≥7.5%, OR documentation of established cardiovascular disease
- For continuation: documentation of A1C reduction since starting therapy, OR documentation of established cardiovascular disease
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- Renewal: Improvement in A1C.
- Renewal: Member has been receiving the requested drug for at least 3 months AND has demonstrated a reduction in A1C since starting therapy; OR has established cardiovascular disease. CVD pathway does not require A1C re-verification at continuation.
Not covered when
- Pancreatitis history (consider other antidiabetic therapies)
- Type 1 diabetes
Policy note: Policy also requires that members either be unable to use or have tried and failed preferred formulary medications first (non-formulary requests subject to PG069). Ozempic is listed under FDA-approved indications for both T2DM glycemic control and CV risk reduction in adults with T2DM and established CVD, but this guideline covers only antidiabetic use; Wegovy is handled under a separate weight loss agents guideline (PG070). No quantity limits specified in this document.
source: Oscar Health Employer / Commercial Insurance prior authorization policy · View policy document (PDF)