Applies to Medicaid plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
Standard pathway: prior oral antidiabetic agent use
All of:
- Age ≥ 18 years
- Diagnosis of type 2 diabetes in the last 365 days
- History of an oral antidiabetic agent for 14 consecutive days in the last 365 days
- No history of ESRD, pancreatitis, gastroparesis, MTC, or MEN2 in the last 730 days
- No history of ESRD services (CPT codes) in the last 730 days
- HbA1c test in the last 180 days
- No concurrent therapy with a GLP-1 RA containing agent
Alternative pathway: history of requested medication (stable therapy)
All of:
- Age ≥ 18 years
- Diagnosis of type 2 diabetes in the last 365 days
- History of the requested medication for 14 consecutive days in the last 365 days
- No history of ESRD, pancreatitis, gastroparesis, MTC, or MEN2 in the last 730 days
- No history of ESRD services (CPT codes) in the last 730 days
- HbA1c test in the last 180 days
- No concurrent therapy with a GLP-1 RA containing agent
Exception pathway: ASCVD, HF, or CKD without prior oral antidiabetic agent (age ≥ 18 only)
All of:
- Age ≥ 18 years
- Diagnosis of type 2 diabetes in the last 365 days
- No history of oral antidiabetic agent for 14 consecutive days in the last 365 days
- No history of requested medication for 14 consecutive days in the last 365 days
- History of ASCVD, HF, or CKD in the last 365 days
- No history of ESRD, pancreatitis, gastroparesis, MTC, or MEN2 in the last 730 days
- No history of ESRD services (CPT codes) in the last 730 days
- HbA1c test in the last 180 days
- No concurrent therapy with a GLP-1 RA containing agent
Documentation to bring
- Type 2 diabetes diagnosis (ICD-10 code from Table 3) within last 365 days
- History of oral antidiabetic agent for 14 consecutive days in the last 365 days (Table 4) OR history of requested medication for 14 consecutive days in the last 365 days (Table 5) OR documentation of ASCVD, HF, or CKD (ICD-10 from Table 6) within last 365 days
- HbA1c test (CPT 83036 or 83037) within the last 180 days
- Absence of ESRD, pancreatitis, gastroparesis, MTC, or MEN2 diagnosis in the last 730 days
- Absence of ESRD services (CPT codes from Table 9) in the last 730 days
- No concurrent GLP-1 RA-containing agent therapy
Approval and renewal
- Initial approval: 12 months
Not covered when
- ESRD (diagnosis or ESRD services CPT codes in last 730 days)
- Pancreatitis (acute or chronic, in last 730 days)
- Gastroparesis (in last 730 days)
- Medullary thyroid carcinoma (MTC) (in last 730 days)
- Multiple endocrine neoplasia syndrome type 2 (MEN2) (in last 730 days)
- Concurrent therapy with a GLP-1 RA containing agent
- Type 1 diabetes
Policy note: Texas Medicaid PA policy. Ozempic is eligible for the ASCVD/HF/CKD exception pathway (Step 6) when the patient lacks prior oral antidiabetic therapy, but only for patients ≥ 18 years (Step 7 age check applies). The ASCVD/HF/CKD ICD-10 codes in Table 6 include extensive cerebrovascular, cardiac, PAD, and CKD stage 1-5/ESRD codes. Note: CKD stage 1-5 and ESRD are both in Table 6 as qualifying ASCVD/HF/CKD comorbidities, but ESRD separately triggers a denial at Steps 8 and 9. Bydureon BCise Ozempic GCN 44164 was removed from the PA table as discontinued. No quantity limits specified.
Policy effective October 31, 2025 · verified June 4, 2026 · source: GLP-1 R Apending · View policy document (PDF)