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PacificSource Health · Type 2 Diabetes

PacificSource Health coverage for Ozempic (Type 2 Diabetes)

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

All Ozempic policies under PacificSource Health · Check your card