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
- 0.25mg, 0.5mg, 1mg, 2mg — 4 injections
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 4 injections per month. PA form required: GLP-1 Agonist PA Form. Policy note states A1C level can be from early stages in treatment; if original HbA1c is unknown or current HbA1c is controlled due to another diabetic regimen, prescriber should include current regimen and current A1C. Renewal requires positive clinical response plus re-attestation of DPP-4 and GLP-1 co-administration exclusions. No metformin step therapy or BMI requirement specified.
Policy effective June 1, 2026 · verified June 3, 2026 · source: Criteria-PDL.pdf