Does Massachusetts Medicaid cover Ozempic?

What you need to qualify

• Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Appropriate diagnosis of type 2 diabetes
• Baseline A1C lab result dated within 90 days prior to initiation
• Attestation that requested agent will not be used in combination with another GLP-1 receptor agonist
• If quantity exceeds limits: clinical rationale why dose cannot be consolidated or for exceeding FDA-approved dosing
• For recertification: current A1C dated within last 90 days
• For recertification: evidence of A1C reduction, A1C ≤ 7%, or treatment plan for A1C escalation

Quantity limits

• all strengths — 1 prefilled pen per 28-day supply

Approval and renewal

• To renew, the plan looks for improvement in A1C and Current A1C within last 90 days required. Must show: reduction in A1C since initiation, OR A1C ≤ 7% (dated within last 90 days), OR treatment plan addressing escalation of therapy for A1C reduction.

Not covered when

• Combination use with another GLP-1 receptor agonist is prohibited unless transitioning (with discontinuation of prior GLP-1)

Policy note: Ozempic is a Preferred Drug (PD) in the MassHealth formulary for type 2 diabetes. No step therapy through lower-potency GLP-1s is required for initial approval for T2DM (unlike Bydureon/Rybelsus which require prior failure of high-potency GLP-1s including Ozempic). SmartPA pathway allows claims to process without PA request if member has T2DM claims history and GLP-1 claims history meeting criteria. Prediabetes indication is also covered under a separate pathway (see notes for liraglutide/Mounjaro/Ozempic/Trulicity section) requiring metformin trial or exception plus step through liraglutide (Victoza) and Trulicity before Ozempic is approved for prediabetes.

verified June 4, 2026 · source: policy-348.html

What you need to qualify

• On guideline-directed medical therapy (ACE_inhibitor and ARB)
• eGFR no higher than 75
• Urine albumin-to-creatinine ratio of 100 or higher
• Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Appropriate diagnosis of type 2 diabetes and chronic kidney disease
• eGFR lab result (≤ 75 mL/min/1.73 m²) dated within last 90 days
• Urinary albumin-to-creatinine ratio (UACR) lab result: > 300 and < 5,000 mg/g if eGFR ≥ 50, OR > 100 and < 5,000 mg/g if eGFR < 50
• Documentation of current ACE-I or ARB use, OR adverse reaction to one ACE-I or ARB, OR contraindication to all ACE-Is and ARBs
• Documentation of inadequate response or adverse reaction to dapagliflozin or Jardiance, or contraindication to both
• Attestation that requested agent will not be used in combination with another GLP-1 receptor agonist
• If quantity exceeds limits: clinical rationale why dose cannot be consolidated or for exceeding FDA-approved dosing

Quantity limits

• all strengths — 1 prefilled pen per 28-day supply

Not covered when

• Combination use with another GLP-1 receptor agonist is prohibited
• UACR ≥ 5,000 mg/g excludes coverage
• eGFR > 75 excludes coverage

Policy note: The CKD indication requires T2DM as a co-diagnosis. eGFR must be ≤ 75 mL/min/1.73 m². UACR threshold differs based on eGFR: for eGFR ≥ 50, UACR must be > 300 and < 5,000 mg/g; for eGFR < 50, UACR must be > 100 and < 5,000 mg/g. SGLT2 inhibitor step therapy (dapagliflozin and Jardiance) required. ACE-I/ARB use required or exception documented. This is listed as an FDA-approved indication: 'Type 2 diabetes mellitus and chronic kidney disease (Ozempic)' in the document.

verified June 4, 2026 · source: policy-348.html