Skip to content

PacificSource Health

Does PacificSource Health cover Ozempic for Kidney Disease (CKD)?

Yes. PacificSource Health covers Ozempic for kidney disease (CKD) with prior authorization. Other policy requirements and your plan's benefits also apply.

Policy documents

  • Employer and ACA Marketplace: Covered with requirements. See the qualification pathways below.
  • Medicaid: Covered with requirements. See the qualification pathways below.

Earliest policy review June 10, 2026. How we verify · Check your exact plan

Full requirements: Ozempic for Kidney Disease (CKD) (3 plan types)

Applies to Employer and ACA Marketplace plans.

Covered with requirements

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
  • Renewal: 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 · View policy document (PDF)

Applies to Medicaid plans.

Covered with requirements

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
  • Renewal: 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 · View policy document (PDF)

Open on its own page →

Questions people ask
Does PacificSource Health cover Ozempic?
Yes. PacificSource Health covers Ozempic for kidney disease (CKD) with prior authorization. Other policy requirements and your plan's benefits also apply.
How long does a Ozempic approval last with PacificSource Health?
Kidney Disease (CKD) — Applies to Employer and ACA Marketplace plans. Initial approval: 24 months. Renewal: every 24 months. Kidney Disease (CKD) — Applies to Medicaid plans. Initial approval: 12 months. Renewal: every 12 months.
What does PacificSource Health require to renew Ozempic?
Kidney Disease (CKD) — Applies to Employer and ACA Marketplace plans. Documentation of disease responsiveness to therapy required at reauthorization. Kidney Disease (CKD) — Applies to Medicaid plans. Documentation of treatment success and a clinically significant response to therapy.
How current is this information?
The oldest review date among the policies on this page is June 10, 2026. Each policy's effective and verification dates appear with its requirements. Confirm current benefits with your plan.

Also under PacificSource Health: Mounjaro, Wegovy

Ozempic under other plans: Kaiser Permanente Northwest, Oregon Medicaid, Regence, Alabama Medicaid, Arkansas Medicaid, California Medicaid, Clover Health, Colorado Medicaid

All insurance plans · All medications

Summary of PacificSource Health's written policy, not a guarantee of coverage. Plans vary by employer and benefit design.