PacificSource Health

Does PacificSource Health cover Ozempic?

Quick answer · Type 2 Diabetes

PacificSource Health covers Ozempic for type 2 diabetes with prior authorization on Employer / Commercial Insurance, Medicaid, and ACA Marketplace.

  • Employer / Commercial Insurance: Covered with requirements. Diagnosis documented with a code
  • Medicaid: Covered with requirements. A1C of 7% or higher
  • ACA Marketplace: Covered with requirements. Diagnosis documented with a code

Last verified June 10, 2026. Policy effective June 22, 2026. Source: cw577pv8jf and 2023-Medicaid-Preapproval-Criteria-05152023.pdf. How we verify this data →

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Ozempic for Type 2 Diabetes

What PacificSource Health requires, by plan type. Open this indication on its own page →

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

  • Diagnosis documented with a code
  • Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Type 2 Diabetes

All of:

  • Diagnosis of Type 2 diabetes confirmed with lab testing
  • No concurrent use of other GLP-1 receptor agonists
  • Not using for weight loss or other excluded diagnosis
  • Not in diabetes remission (HbA1c < 6.5% for at least 3 months without glucose-lowering therapy)

Documentation to bring

  • Lab confirmation of Type 2 diabetes diagnosis
  • Claims history and ICD-10 codes reviewed
  • Documentation that patient is not using concurrently with another GLP-1 receptor agonist

Approval and renewal

  • Initial approval: 24 months
  • Renewal: every 24 months
  • To renew, the plan looks for Documentation of disease responsiveness to therapy required at reauthorization.

Not covered when

  • Use for weight loss or other excluded diagnosis
  • Dosing above FDA-approved label for treatment of diabetes
  • Diabetes remission (HbA1c < 6.5% persisting ≥3 months without usual glucose-lowering therapy)
  • History of ketoacidosis
  • Concurrent use of other GLP-1 receptor agonists

Policy note: Policy covers all FDA-approved indications not otherwise excluded by plan design. Covered uses include T2DM, T2DM with cardiovascular disease, and T2DM with CKD. Authorization duration is 24 months unless otherwise specified.

Policy effective June 22, 2026 · verified June 10, 2026 · source: cw577pv8jf

Medicaid

Covered with requirements

What you need to qualify

  • Age 18 and older
  • A1C of 7% or higher
  • Prior trial of another GLP-1 medication (liraglutide) for at least 84 days
  • Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

T2DM New Start — Step Therapy

All of:

  • Diagnosis of Type 2 diabetes
  • A1C >= 7%
  • Age >= 18 years

Plus any one of:

  • Inadequate treatment response following minimum 12-week trial of liraglutide
  • Evidence of adverse effect with liraglutide (not attributable to the GLP-1 class) after adequate dose titration

Documentation to bring

  • Documentation of Type 2 diabetes diagnosis
  • Recent hemoglobin A1c >= 7%
  • Documentation of inadequate response to minimum 12-week liraglutide trial OR evidence of adverse effect with liraglutide not attributable to the GLP-1 class after adequate dose titration

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • To renew, the plan looks for Documentation of treatment success and a clinically significant response to therapy.

Not covered when

  • Weight loss indication excluded

Policy note: Policy covers all FDA-approved indications not otherwise excluded by plan design. Step therapy requires prior liraglutide trial (12 weeks) or adverse effect to liraglutide specifically (not class-wide). Age restriction for Ozempic is >= 18 years.

Policy effective May 15, 2026 · verified June 10, 2026 · source: 2023-Medicaid-Preapproval-Criteria-05152023.pdf

ACA Marketplace

Covered with requirements

What you need to qualify

  • Diagnosis documented with a code
  • Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Type 2 Diabetes

All of:

  • Diagnosis of Type 2 diabetes confirmed with lab testing
  • No concurrent use of other GLP-1 receptor agonists
  • Not using for weight loss or other excluded diagnosis
  • Not in diabetes remission (HbA1c < 6.5% for at least 3 months without glucose-lowering therapy)

Documentation to bring

  • Lab confirmation of Type 2 diabetes diagnosis
  • Claims history and ICD-10 codes reviewed
  • Documentation that patient is not using concurrently with another GLP-1 receptor agonist

Approval and renewal

  • Initial approval: 24 months
  • Renewal: every 24 months
  • To renew, the plan looks for Documentation of disease responsiveness to therapy required at reauthorization.

Not covered when

  • Use for weight loss or other excluded diagnosis
  • Dosing above FDA-approved label for treatment of diabetes
  • Diabetes remission (HbA1c < 6.5% persisting ≥3 months without usual glucose-lowering therapy)
  • History of ketoacidosis
  • Concurrent use of other GLP-1 receptor agonists

Policy note: Policy covers all FDA-approved indications not otherwise excluded by plan design. Covered uses include T2DM, T2DM with cardiovascular disease, and T2DM with CKD. Authorization duration is 24 months unless otherwise specified.

Policy effective June 22, 2026 · verified June 10, 2026 · source: cw577pv8jf

Ozempic for Heart Disease Risk Reduction

What PacificSource Health requires, by plan type. Open this indication on its own page →

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

  • Diagnosis documented with a code
  • Established cardiovascular disease
  • Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

T2DM with Cardiovascular Disease (FDA-approved indication)

All of:

  • Diagnosis of Type 2 diabetes confirmed with lab testing
  • Diagnosis of cardiovascular disease
  • No concurrent use of other GLP-1 receptor agonists
  • Not using for weight loss or other excluded diagnosis

Documentation to bring

  • Lab confirmation of Type 2 diabetes diagnosis
  • Documentation of cardiovascular disease diagnosis
  • Claims history and ICD-10 codes reviewed

Approval and renewal

  • Initial approval: 24 months
  • Renewal: every 24 months
  • To renew, the plan looks for Documentation of disease responsiveness to therapy required at reauthorization.

Not covered when

  • Use for weight loss or other excluded diagnosis
  • Concurrent use of other GLP-1 receptor agonists
  • History of ketoacidosis

Policy note: Covered as FDA-approved indication 'T2DM and cardiovascular disease'. Policy does not exclude T2DM patients for this indication — this is distinct from Wegovy's CV indication which does not require T2DM.

Policy effective June 22, 2026 · verified June 10, 2026 · source: cw577pv8jf

ACA Marketplace

Covered with requirements

What you need to qualify

  • Diagnosis documented with a code
  • Established cardiovascular disease
  • Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

T2DM with Cardiovascular Disease (FDA-approved indication)

All of:

  • Diagnosis of Type 2 diabetes confirmed with lab testing
  • Diagnosis of cardiovascular disease
  • No concurrent use of other GLP-1 receptor agonists
  • Not using for weight loss or other excluded diagnosis

Documentation to bring

  • Lab confirmation of Type 2 diabetes diagnosis
  • Documentation of cardiovascular disease diagnosis
  • Claims history and ICD-10 codes reviewed

Approval and renewal

  • Initial approval: 24 months
  • Renewal: every 24 months
  • To renew, the plan looks for Documentation of disease responsiveness to therapy required at reauthorization.

Not covered when

  • Use for weight loss or other excluded diagnosis
  • Concurrent use of other GLP-1 receptor agonists
  • History of ketoacidosis

Policy note: Covered as FDA-approved indication 'T2DM and cardiovascular disease'. Policy does not exclude T2DM patients for this indication — this is distinct from Wegovy's CV indication which does not require T2DM.

Policy effective June 22, 2026 · verified June 10, 2026 · source: cw577pv8jf

Ozempic for Kidney Disease (CKD)

What PacificSource Health requires, by plan type. Open this indication on its own page →

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

  • Diagnosis documented with a code
  • Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

T2DM with Chronic Kidney Disease (FDA-approved indication)

All of:

  • Diagnosis of Type 2 diabetes confirmed with lab testing
  • Diagnosis of chronic kidney disease (CKD)
  • No concurrent use of other GLP-1 receptor agonists
  • Not using for weight loss or other excluded diagnosis

Documentation to bring

  • Lab confirmation of Type 2 diabetes diagnosis
  • Documentation of CKD diagnosis
  • Claims history and ICD-10 codes reviewed

Approval and renewal

  • Initial approval: 24 months
  • Renewal: every 24 months
  • To renew, the plan looks for Documentation of disease responsiveness to therapy required at reauthorization.

Not covered when

  • Polycystic kidney disease or glomerulonephritis
  • Use for weight loss or other excluded diagnosis
  • Concurrent use of other GLP-1 receptor agonists
  • History of ketoacidosis

Policy note: Covered as FDA-approved indication 'T2DM and chronic kidney disease'. Polycystic kidney disease and glomerulonephritis are explicitly excluded. No eGFR or UACR thresholds specified.

Policy effective June 22, 2026 · verified June 10, 2026 · source: cw577pv8jf

Medicaid

Covered with requirements

What you need to qualify

  • Age 18 and older
  • On guideline-directed medical therapy (ACE_inhibitor, ARB, and SGLT2i)
  • Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

CKD + T2DM — High UACR with preserved eGFR

All of:

  • Diagnosis of CKD and T2DM at risk of progression
  • eGFR > 50 mL/min/1.73m²
  • UACR > 300 mg/g
  • On maximum tolerated dose of ACE inhibitor or ARB for at least 4 weeks
  • Documented treatment failure or adverse event with one SGLT2 inhibitor (e.g., dapagliflozin)

CKD + T2DM — Reduced eGFR with elevated UACR

All of:

  • Diagnosis of CKD and T2DM at risk of progression
  • eGFR 25 to < 50 mL/min/1.73m²
  • UACR > 100 mg/g
  • On maximum tolerated dose of ACE inhibitor or ARB for at least 4 weeks
  • Documented treatment failure or adverse event with one SGLT2 inhibitor (e.g., dapagliflozin)

Documentation to bring

  • Diagnosis of CKD and T2DM at risk of progression
  • eGFR lab result (to determine pathway: >50 or 25 to <50 mL/min/1.73m²)
  • UACR lab result (>300 mg/g if eGFR >50; >100 mg/g if eGFR 25 to <50)
  • Documentation of being on maximum tolerated dose of ACE inhibitor or ARB for at least 4 weeks
  • Documented treatment failure or adverse event with at least one SGLT2 inhibitor (e.g., dapagliflozin)

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • To renew, the plan looks for Documentation of treatment success and a clinically significant response to therapy.

Not covered when

  • Weight loss indication excluded

Policy note: Two eGFR/UACR pathways: (1) eGFR >50 with UACR >300 mg/g; (2) eGFR 25 to <50 with UACR >100 mg/g. GDMT required: max tolerated ACE inhibitor or ARB for >=4 weeks AND SGLT2 inhibitor failure/adverse event. Age restriction >= 18 years.

Policy effective May 15, 2026 · verified June 10, 2026 · source: 2023-Medicaid-Preapproval-Criteria-05152023.pdf

ACA Marketplace

Covered with requirements

What you need to qualify

  • Diagnosis documented with a code
  • Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

T2DM with Chronic Kidney Disease (FDA-approved indication)

All of:

  • Diagnosis of Type 2 diabetes confirmed with lab testing
  • Diagnosis of chronic kidney disease (CKD)
  • No concurrent use of other GLP-1 receptor agonists
  • Not using for weight loss or other excluded diagnosis

Documentation to bring

  • Lab confirmation of Type 2 diabetes diagnosis
  • Documentation of CKD diagnosis
  • Claims history and ICD-10 codes reviewed

Approval and renewal

  • Initial approval: 24 months
  • Renewal: every 24 months
  • To renew, the plan looks for Documentation of disease responsiveness to therapy required at reauthorization.

Not covered when

  • Polycystic kidney disease or glomerulonephritis
  • Use for weight loss or other excluded diagnosis
  • Concurrent use of other GLP-1 receptor agonists
  • History of ketoacidosis

Policy note: Covered as FDA-approved indication 'T2DM and chronic kidney disease'. Polycystic kidney disease and glomerulonephritis are explicitly excluded. No eGFR or UACR thresholds specified.

Policy effective June 22, 2026 · verified June 10, 2026 · source: cw577pv8jf

Why Ozempic requests get denied by PacificSource Health

Based on what this policy asks for. Fix these before the first submission.

  1. Wrong brand for the diagnosis. Ozempic and Wegovy are the same molecule with different approved uses; a request for Ozempic under a diagnosis that matches Wegovy is routinely denied.
  2. Diagnosis code missing or wrong on the request.
  3. No recent A1C result on file.
  4. Required prior medication trials not documented.

Frequently asked questions

Does PacificSource Health cover Ozempic?
PacificSource Health covers Ozempic for type 2 diabetes with prior authorization on Employer / Commercial Insurance, Medicaid, and ACA Marketplace.
How long does a Ozempic approval last with PacificSource Health?
Initial approvals last 24 months, and renewals are granted in 24-month periods.
What does PacificSource Health require to renew Ozempic?
Documentation of disease responsiveness to therapy required at reauthorization.
How current is this information?
This page reflects PacificSource Health's written policy as of June 22, 2026, last verified against the source document on June 10, 2026.

Other medications under PacificSource Health

Ozempic coverage under other plans

All insurance plans · All medications

This page summarizes PacificSource Health's written prior-authorization policy. It is not a guarantee of coverage; plans vary by employer and benefit design. Verify with your plan before relying on it.