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PacificSource Health · Kidney Disease (CKD)

PacificSource Health coverage for Ozempic (Kidney Disease (CKD))

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

All Ozempic policies under PacificSource Health · Check your card