Medicaid
Covered (preferred drug)What you need to qualify
- A1C of 6.5% or higher
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
Initial approval for Type 2 Diabetes
All of:
- Submission of medical records confirming T2DM diagnosis
- Will not be used concomitantly with DPP-4 inhibitors
- Will not be co-administered with another GLP-1 receptor agonist
- No personal or immediate family history of medullary thyroid carcinoma or MEN2
Plus any one of:
- A1C >= 6.5%
- Fasting plasma glucose >= 126 mg/dL
- 2-hour plasma glucose >= 200 mg/dL during oral glucose tolerance test
- Random plasma glucose >= 200 mg/dL in patient with classic symptoms of hyperglycemia or hyperglycemic crisis
Documentation to bring
- Medical records (e.g., chart notes) confirming diagnosis of type 2 diabetes
- Lab result confirming one of: A1C >= 6.5%, FPG >= 126 mg/dL, 2-hour PG >= 200 mg/dL during OGTT, or random plasma glucose >= 200 mg/dL with classic hyperglycemia symptoms
- Documentation that patient has no personal or immediate family history of medullary thyroid carcinoma or MEN2
Quantity limits
- 2.5mg, 5mg, 7.5mg, 10mg, 12.5mg, 15mg — 2 mL
Approval and renewal
- To renew, the plan looks for improvement in A1C and Positive clinical response required: reduction in HbA1C, HbA1C goal achieved, improvement in fasting blood glucose levels, or improvement in ASCVD. DPP-4 inhibitor exclusion and GLP-1 co-administration exclusion re-verified at renewal.
Not covered when
- Personal or immediate family history of medullary thyroid carcinoma or MEN2
- Concomitant use of DPP-4 inhibitors
- Co-administration with another GLP-1 receptor agonist
Policy note: Quantity limit is 2 mL per 28 days. PA form required: GLP-1 Agonist PA Form. Renewal requires positive clinical response documentation plus re-attestation of DPP-4 and GLP-1 co-administration exclusions. No A1C metformin step therapy or BMI requirement specified.
Policy effective June 1, 2026 · verified June 3, 2026 · source: Criteria-PDL.pdf