Medicaid
Covered with requirementsWhat you need to qualify
- A1C of 7% or higher
- Diagnosis documented with a code
- Prior trial of another GLP-1 medication (Ozempic) for at least 120 days
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
Initial Approval - Full Step Therapy (Ozempic trial completed)
All of:
- Diagnosis of Type 2 Diabetes Mellitus (T2DM)
- Current A1C greater than 7% (within the last 6 months)
- Prescriber has listed patient's goal A1C value
- Patient has tried THREE preferred medications titrated to maximum treatment doses for 120 days and was unable to reach A1C goal
- One of the three preferred drugs must be a preferred GLP-1 receptor agonist (BYETTA, exenatide, VICTOZA, liraglutide, or TRULICITY)
- The preferred GLP-1 medication was used concurrently with at least one other preferred non-insulin medication in the Endocrine Agents: Diabetes - Non-Insulin UPDL category for 120 days
- Patient had documented adherence with medications
- Doses were titrated to maximum treatment dose for 120 days
- Patient has used Ozempic for at least 120 days at maximum recommended dose and was unable to reach A1C goal with documented adherence
Initial Approval - GI Intolerance to preferred GLP-1 with Ozempic medical necessity exception
All of:
- Diagnosis of Type 2 Diabetes Mellitus (T2DM)
- Current A1C greater than 7% (within the last 6 months)
- Prescriber has listed patient's goal A1C value
- Patient was unable to complete 120 days of preferred GLP-1 due to gastrointestinal (GI) intolerance
- Chart documentation submitted that dietary changes, prescription antiemetics, and dose adjustment were each tried for at least 30 days
Plus any one of:
- Patient has used Ozempic for at least 120 days at maximum recommended dose and was unable to reach A1C goal with documented adherence
- Documentation of medical necessity for patient's inability to use Ozempic provided
Initial Approval - Ozempic GI Intolerance Exception
All of:
- Diagnosis of Type 2 Diabetes Mellitus (T2DM)
- Current A1C greater than 7% (within the last 6 months)
- Prescriber has listed patient's goal A1C value
- Patient has tried THREE preferred medications titrated to maximum treatment doses for 120 days and was unable to reach A1C goal
- One of the three preferred drugs must be a preferred GLP-1 receptor agonist (BYETTA, exenatide, VICTOZA, liraglutide, or TRULICITY)
- Patient was unable to complete 120 days of Ozempic due to GI intolerance
- Chart documentation submitted that dietary changes, prescription antiemetics, and dose adjustment for Ozempic GI intolerance were each tried for at least 30 days
Documentation to bring
- ICD-10 diagnosis code for Type 2 Diabetes Mellitus (T2DM)
- Current A1C lab result within the last 6 months demonstrating A1C > 7%
- Prescriber-documented goal A1C value with justification if more stringent than <7%
- Documentation of three preferred medications titrated to maximum doses for 120 days with names, doses, and dates of use
- Documentation that one preferred GLP-1 agonist (BYETTA, exenatide, VICTOZA, liraglutide, or TRULICITY) was used concurrently with at least one other preferred non-insulin medication
- Documentation of patient adherence with trial medications
- Dates and doses of Ozempic use for at least 120 days at maximum recommended dose with documentation of inadequate response; OR documentation of medical necessity for inability to use Ozempic
- If Ozempic GI intolerance: chart documentation that dietary changes, prescription antiemetics, and dose adjustment were each tried for at least 30 days with patient response described
- If maximum doses of preferred GLP-1 or Ozempic were not reached: clinical reason documented
Approval and renewal
- Renewal: every 12 months
- To renew, the plan looks for improvement in A1C and Patient must show improvement in A1C from baseline when the requested medication was started. Current A1C (within last 6 months) and baseline A1C must be submitted. Prescriber must also attest patient is being monitored for safety and efficacy. Prior authorization approval from Gainwell within the last year must be documented. Patient must have received medication under ODM benefit (not samples) within the last 365 days. Note: A1C >7% requirement and Ozempic step-therapy are initial criteria only and are not re-verified at renewal.
Not covered when
- Requests for conditions other than T2DM will not be approved per FDA approved labeling
- Obesity treatment is explicitly not covered under Ohio Medicaid per OAC 5160-9-03
- EPSDT exception available for patients under age 21 via Standard PA Fillable Form
- Type 1 diabetes
Policy note: Mounjaro requires completion of Sections A, B, and C for initial requests. It has an additional step-therapy requirement specific to Ozempic (120 days at maximum dose with inadequate response, or medical necessity documentation for inability to use Ozempic) in addition to the standard 3-drug preferred trial required for all non-preferred GLP-1s. The A1C >7% threshold applies specifically to Mounjaro initial requests (Section C). Renewal requires Sections A and D only. Separate PA forms exist for Zepbound (OSA) and Wegovy (non-obesity indications) at https://spbm.medicaid.ohio.gov/.
Policy effective April 1, 2026 · verified June 4, 2026 · source: Pa policy