Employer / Commercial Insurance
Covered with requirementsWhat you need to qualify
- Age 18 and older
- A1C of 6.5% or higher
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
New T2DM diagnosis (diagnosed <= 2 years ago)
All of:
- Submission of medical records (e.g., chart notes) confirming diagnosis of type 2 diabetes mellitus
Plus any one of:
- A1C >= 6.5%
- Fasting plasma glucose (FPG) >= 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
Ongoing T2DM treatment (diagnosed > 2 years ago)
All of:
- Submission of medical records (e.g., chart notes) confirming diagnosis of type 2 diabetes mellitus
- Patient diagnosed greater than 2 years ago
Documentation to bring
- Medical records (e.g., chart notes) confirming diagnosis of type 2 diabetes mellitus
- For new diagnosis (<=2 years): at least one qualifying lab value (A1C >= 6.5%, FPG >= 126 mg/dL, 2-hr PG >= 200 mg/dL on OGTT, or random PG >= 200 mg/dL with classic hyperglycemia symptoms)
- For ongoing treatment (>2 years): chart notes confirming T2DM diagnosis
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- To renew, the plan looks for Re-authorization may be based solely on previous claim/medication history, diagnosis codes (ICD-10), and/or claim logic via automated processes.
Not covered when
- Not approved for weight loss; use solely for weight loss is not covered
- Type 1 diabetes
Policy note: This policy covers Ozempic for T2DM under this PA program. Ozempic also has FDA-approved CV risk reduction and CKD indications noted in the background section, but this PA policy only establishes criteria based on T2DM diagnosis. Automated approval/re-approval processes may apply. Supply limits may be in place.
Policy effective July 1, 2025 · verified June 2, 2026 · source: PA-Notification-Diabetes-Agents-GLP1-Receptor-Agonists.pdf