Applies to Employer and ACA Marketplace plans.
Covered (preferred drug)Qualification pathways
You can qualify through any one of these.
Route 1: Type 2 Diabetes Diagnosis
All of:
- Diagnosis of type 2 diabetes (T2DM)
Route 2: Point-of-Sale Clinical Edit (ICD-10 or prior therapy claims)
Plus any one of:
- ICD-10 code for type 2 diabetes (E11*) within the past 2 years
- Adjudicated and paid claims for a contingent therapy (biguanides, insulin, amylin analogs, sulfonylureas, meglitinide analogues, alpha-glucosidase inhibitors, DPP-4 inhibitors, insulin sensitizing agents, SGLT2 inhibitors, or antidiabetic combinations) — 56-day supply in 120 days
- Auto-grandfather: prior paid claim for Mounjaro, Ozempic, Rybelsus, or Trulicity within 120 days
Documentation to bring
- Diagnosis of type 2 diabetes OR ICD-10 code E11* within past 2 years OR adjudicated claims for qualifying contingent antidiabetic therapy (56-day supply in 120 days)
- Chart notes or clinical documentation confirming medical necessity and clinical benefit (for continuation)
Quantity limits
- all available injectable strengths — 1 pen per 28 days
- tablet formulation (semaglutide tablets) — 30 tablets per 30 days
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- Renewal: Clinical documentation (such as chart notes) must confirm that current medical necessity criteria are met and that the medication is providing clinical benefit, such as disease stability or improvement.
Not covered when
- Diabetic ketoacidosis (DKA)
- Islet-cell transplantation
- Use in combination with Symlin (pramlintide) or another GLP-1 agonist-containing medication
- Weight loss in the absence of coverable medical conditions
- Type 1 diabetes
Policy note: Policy covers Ozempic under the pharmacy benefit only (self-administered). As of the 3/16/2026 revision, Ozempic (semaglutide) tablets were added to the policy; Rybelsus (semaglutide) tablets will remain in policy until existing supply is exhausted. Quantity limit for injectable is 1 pen per 28 days OR 30 tablets per 30 days. Point-of-sale clinical edits in Appendix 1 provide an alternative pathway. Authorization reviewed at least annually. The document references CKD trial data for Ozempic in the background section but does NOT establish separate PA criteria for a CKD or CV risk reduction indication under this policy — this policy covers Ozempic exclusively for type 2 diabetes.
Policy effective April 15, 2026 · verified June 3, 2026 · source: Dru750reg · View policy document (PDF)