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PacificSource Health

Does PacificSource Health cover Ozempic for Type 2 Diabetes?

Yes. PacificSource Health covers Ozempic for type 2 diabetes 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 Type 2 Diabetes (3 plan types)

Applies to Employer and ACA Marketplace plans.

Covered with requirements

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
  • Renewal: 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 · View policy document (PDF)

Applies to Medicaid plans.

Covered with requirements

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
  • Renewal: 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 · View policy document (PDF)

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Questions people ask
Does PacificSource Health cover Ozempic?
Yes. PacificSource Health covers Ozempic for type 2 diabetes with prior authorization. Other policy requirements and your plan's benefits also apply.
How long does a Ozempic approval last with PacificSource Health?
Type 2 Diabetes — Applies to Employer and ACA Marketplace plans. Initial approval: 24 months. Renewal: every 24 months. Type 2 Diabetes — Applies to Medicaid plans. Initial approval: 12 months. Renewal: every 12 months.
What does PacificSource Health require to renew Ozempic?
Type 2 Diabetes — Applies to Employer and ACA Marketplace plans. Documentation of disease responsiveness to therapy required at reauthorization. Type 2 Diabetes — 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.