Pennsylvania Medicaid coverage for Ozempic (Type 2 Diabetes)

No additional clinical requirements are listed beyond the diagnosis.

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Documentation of diabetes diagnosis OR history of qualifying antidiabetic drug use within last 120 days
• Documentation that beneficiary is age-appropriate per FDA labeling, compendia, or peer-reviewed literature
• Documentation of no contraindication to the prescribed drug
• Documentation addressing therapeutic duplication if a recent paid claim for another GLP-1 or DPP-4 inhibitor exists

Approval and renewal

• Initial approval: 12 months
• Renewal: every 12 months
• To renew, the plan looks for Renewal requires: diagnosis of diabetes OR history of antidiabetic drug (excluding metformin, SGLT-2 inhibitors, and GLP-1s) within last 120 days. No weight-loss or BMI criteria re-checked at renewal since obesity indication is excluded.

Not covered when

• Saxenda (liraglutide) is not covered for any indication
• Overweight and obesity treatment indications are excluded for all GLP-1 receptor agonists

Policy note: Ozempic is a preferred GLP-1 receptor agonist for diabetes on the Pennsylvania MA Statewide PDL. Non-preferred GLP-1s for diabetes require: (1) diabetes diagnosis, (2) therapeutic failure of, contraindication to, or intolerance to the maximum FDA-approved dose of preferred GLP-1(s) approved for the beneficiary's diagnosis, and (3) the requested drug must be FDA-approved for diabetes. All prescriptions are limited to a one-month supply per fill. Therapeutic duplication rules apply: if a recent paid claim exists for another GLP-1 or DPP-4 inhibitor, must document intent to transition off one drug or a medical reason for concomitant use supported by literature or guidelines. A physician reviewer may approve requests that do not meet standard guidelines if deemed medically necessary.

Policy effective January 1, 2026 · verified June 4, 2026 · source: mab2025112403.pdf