Washington Medicaid

Does Washington Medicaid cover Ozempic?

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Quick answer · Type 2 Diabetes

Washington Medicaid covers Ozempic for type 2 diabetes with prior authorization on Medicaid.

  • Medicaid: Covered with requirements. A1C of 6.5% or higher

Last verified June 4, 2026. Policy effective June 1, 2026. Source: antidiabetics-GLP-1-agonists.pdf. How we verify this data →

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Ozempic for Type 2 Diabetes

What Washington Medicaid requires, by plan type. Open this indication on its own page →

Medicaid

Covered with requirements

What you need to qualify

  • Age 18 and older
  • A1C of 6.5% or higher
  • Trial of metformin for at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication", "clinically_inappropriate"])
  • Prior trial of another GLP-1 medication (liraglutide) for at least 90 days
  • Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Non-preferred agent (Ozempic) for T2DM — initial approval

All of:

  • Diagnosis of type 2 diabetes OR HbA1c ≥ 6.5 within the last 12 months
  • Patient is ≥ 18 years old
  • Drug will not be used in combination with another GLP-1 agonist or DPP4 inhibitor
  • History of failure (inability to achieve HbA1c < 7%) on metformin at maximum or highest tolerated dose for a minimum of 90 continuous days (unless not tolerated, contraindicated, or clinically inappropriate)
  • History of failure (inability to achieve HbA1c < 7%) on liraglutide at maximum or highest tolerated dose for a minimum of 90 continuous days (unless not tolerated, contraindicated, or clinically inappropriate)

Documentation to bring

  • Diagnosis of type 2 diabetes OR HbA1c lab result ≥ 6.5 within the last 12 months
  • Documentation of patient age (≥ 18 years)
  • Documentation confirming drug will not be combined with another GLP-1 agonist or DPP4 inhibitor
  • Documentation of metformin trial at maximum or highest tolerated dose for ≥ 90 continuous days with inadequate response (HbA1c not achieving <7%), OR documentation of intolerance/contraindication/clinical inappropriateness
  • Documentation of liraglutide trial at maximum or highest tolerated dose for ≥ 90 continuous days with inadequate response (HbA1c not achieving <7%), OR documentation of intolerance/contraindication/clinical inappropriateness

Quantity limits

  • 0.25mg/0.5mL, 0.5mg/0.5mL, 1mg/0.5mL — 3 mL per 28 days (2 mg/3 mL pen injector)
  • 1mg/0.5mL (4mg/3mL pen) — 3 mL per 28 days (4 mg/3 mL pen injector)
  • 2mg/0.5mL (8mg/3mL pen) — 3 mL per 28 days (8 mg/3 mL pen injector)

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • To renew, the plan looks for improvement in A1C and HbA1c ≤ 7 OR improved from baseline prior to GLP-1 treatment; diagnosis of T2DM confirmed; not used in combination with another GLP-1 agonist or DPP4 inhibitor. BMI and prior therapy step requirements are NOT re-verified at continuation.

Not covered when

  • Concurrent use with another GLP-1 agonist
  • Concurrent use with a DPP4 inhibitor

Policy note: Ozempic is a non-preferred agent on the Apple Health PDL. As a non-preferred brand, it requires step-through of BOTH metformin AND liraglutide (the preferred agents) for the standard T2DM indication. The a1c_min of 6.5 reflects the diagnostic threshold; the step-therapy failure threshold is HbA1c remaining ≥ 7% despite preferred agents. A1c must have been measured within the last 12 months.

Policy effective June 1, 2026 · verified June 4, 2026 · source: antidiabetics-GLP-1-agonists.pdf

Ozempic for Heart Disease Risk Reduction

What Washington Medicaid requires, by plan type. Open this indication on its own page →

Medicaid

Covered with requirements

What you need to qualify

  • Age 18 and older
  • BMI of 30 or higher
  • BMI of 27 or higher with a weight-related condition
  • A1C of 6.5% or higher
  • Established cardiovascular disease (prior_stroke, prior_MI, symptomatic_carotid_artery_disease, symptomatic_coronary_artery_disease, and symptomatic_PAD)
  • Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Ozempic for T2DM with established CVD — BMI > 30 kg/m²

All of:

  • Diagnosis of type 2 diabetes OR HbA1c ≥ 6.5 within the last 12 months
  • Patient is ≥ 18 years old
  • Drug will not be used in combination with another GLP-1 agonist or DPP4 inhibitor
  • BMI > 30 kg/m²
  • Established cardiovascular disease (prior stroke, prior MI, symptomatic carotid artery disease, symptomatic CAD, or symptomatic PAD as defined in policy)

Ozempic for T2DM with established CVD — BMI 27–30 kg/m² with liraglutide step-through

All of:

  • Diagnosis of type 2 diabetes OR HbA1c ≥ 6.5 within the last 12 months
  • Patient is ≥ 18 years old
  • Drug will not be used in combination with another GLP-1 agonist or DPP4 inhibitor
  • BMI 27–30 kg/m²
  • Established cardiovascular disease (prior stroke, prior MI, symptomatic carotid artery disease, symptomatic CAD, or symptomatic PAD as defined in policy)
  • History of failure on liraglutide at maximum tolerated dose for a minimum of 90 continuous days (inability to achieve HbA1c < 7%), unless not tolerated, contraindicated, or clinically inappropriate

Documentation to bring

  • Diagnosis of type 2 diabetes OR HbA1c lab result ≥ 6.5 within the last 12 months
  • Documentation of patient age (≥ 18 years)
  • Documentation confirming drug will not be combined with another GLP-1 agonist or DPP4 inhibitor
  • Current BMI measurement (must be > 30 kg/m² for no prior GLP-1 required; 27–30 kg/m² requires liraglutide step-through)
  • Documentation of qualifying established cardiovascular disease event — one of: prior stroke; prior MI; symptomatic carotid artery disease (stenosis >50%, internal carotid revascularization, or TIA with focal neurological symptoms); symptomatic CAD (coronary stenosis ≥50%, symptomatic angina pectoris, or prior coronary revascularization); symptomatic PAD (claudication with ABI <0.85, peripheral arterial revascularization, or amputation due to atherosclerotic disease)
  • If BMI 27–30 kg/m²: Documentation of liraglutide trial at maximum tolerated dose for ≥ 90 continuous days with inadequate response, OR documentation of intolerance/contraindication/clinical inappropriateness

Quantity limits

  • 2mg/3mL pen — 3 mL per 28 days
  • 4mg/3mL pen — 3 mL per 28 days
  • 8mg/3mL pen — 3 mL per 28 days

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • To renew, the plan looks for improvement in A1C and HbA1c ≤ 7 OR improved from baseline prior to GLP-1 treatment; diagnosis of T2DM confirmed; not used in combination with another GLP-1 agonist or DPP4 inhibitor. CV disease documentation and BMI requirements are NOT re-verified at continuation.

Not covered when

  • Concurrent use with another GLP-1 agonist
  • Concurrent use with a DPP4 inhibitor

Policy note: This indication requires T2DM (does NOT exclude diabetes — it is specifically for T2DM patients with established CVD). The policy distinguishes between BMI > 30 (no liraglutide step-through required) and BMI 27–30 (liraglutide step-through required). Specific CVD qualifying conditions are detailed in the policy including carotid artery disease, CAD, and PAD with objective criteria. No GDMT requirement beyond the CVD diagnosis documentation itself.

Policy effective June 1, 2026 · verified June 4, 2026 · source: antidiabetics-GLP-1-agonists.pdf

Ozempic for Kidney Disease (CKD)

What Washington Medicaid requires, by plan type. Open this indication on its own page →

Medicaid

Covered with requirements

What you need to qualify

  • Age 18 and older
  • A1C of 6.5% or higher
  • On guideline-directed medical therapy (ACE_inhibitor and ARB)
  • eGFR of 25 or higher
  • Urine albumin-to-creatinine ratio of 100 or higher
  • Lab results confirming eligibility from the last 12 months

Qualification pathways

You can qualify through any one of these.

Ozempic for CKD in T2DM — eGFR 50–75 with high albuminuria

All of:

  • Diagnosis of type 2 diabetes OR HbA1c ≥ 6.5 within the last 12 months
  • Patient is ≥ 18 years old
  • Drug will not be used in combination with another GLP-1 agonist or DPP4 inhibitor
  • Diagnosis of chronic kidney disease
  • eGFR 50–75 mL/min with UACR > 300 mg/g within the last 12 months
  • Patient is taking an ACE inhibitor or ARB at maximum tolerated dose, unless contraindicated or not tolerated

Ozempic for CKD in T2DM — eGFR 25 to <50 with moderate albuminuria

All of:

  • Diagnosis of type 2 diabetes OR HbA1c ≥ 6.5 within the last 12 months
  • Patient is ≥ 18 years old
  • Drug will not be used in combination with another GLP-1 agonist or DPP4 inhibitor
  • Diagnosis of chronic kidney disease
  • eGFR 25 to <50 mL/min with UACR > 100 mg/g within the last 12 months
  • Patient is taking an ACE inhibitor or ARB at maximum tolerated dose, unless contraindicated or not tolerated

Documentation to bring

  • Diagnosis of type 2 diabetes OR HbA1c lab result ≥ 6.5 within the last 12 months
  • Documentation of patient age (≥ 18 years)
  • Documentation confirming drug will not be combined with another GLP-1 agonist or DPP4 inhibitor
  • Diagnosis of chronic kidney disease
  • eGFR lab result within the last 12 months (must be 50–75 mL/min with UACR >300 mg/g, OR 25 to <50 mL/min with UACR >100 mg/g)
  • UACR lab result within the last 12 months
  • Documentation that patient is taking an ACE inhibitor or ARB at maximum tolerated dose, OR documentation of contraindication or intolerance

Quantity limits

  • 2mg/3mL pen — 3 mL per 28 days
  • 4mg/3mL pen — 3 mL per 28 days
  • 8mg/3mL pen — 3 mL per 28 days

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • To renew, the plan looks for improvement in A1C and HbA1c ≤ 7 OR improved from baseline prior to GLP-1 treatment; diagnosis of T2DM confirmed; not used in combination with another GLP-1 agonist or DPP4 inhibitor. eGFR/UACR lab values and ACE inhibitor/ARB requirement are NOT re-verified at continuation.

Not covered when

  • Concurrent use with another GLP-1 agonist
  • Concurrent use with a DPP4 inhibitor

Policy note: Two eGFR/UACR pathways exist: (1) eGFR 50–75 mL/min requires UACR >300 mg/g; (2) eGFR 25 to <50 mL/min requires UACR >100 mg/g. Both lab values must be within the last 12 months. GDMT here is specifically ACE inhibitor or ARB (not a broad GDMT bundle). egfr_min set to 25 (lower bound of lower pathway); egfr_max left null as the upper pathway goes to 75 — two distinct ranges captured in qualification_pathways. uacr_min set to 100 (the lower threshold applicable to the lower eGFR pathway).

Policy effective June 1, 2026 · verified June 4, 2026 · source: antidiabetics-GLP-1-agonists.pdf

Why Ozempic requests get denied by Washington Medicaid

Based on what this policy asks for. Fix these before the first submission.

  1. Wrong brand for the diagnosis. Ozempic and Wegovy are the same molecule with different approved uses; a request for Ozempic under a diagnosis that matches Wegovy is routinely denied.
  2. BMI not documented in the chart notes (or documented without a baseline weight and date).
  3. Qualifying weight-related condition not documented with its own diagnosis code.
  4. No recent A1C result on file.
  5. No documented metformin trial (dose, dates, and outcome) or a stated reason it can't be used.
  6. Required prior medication trials not documented.

Frequently asked questions

Does Washington Medicaid cover Ozempic?
Washington Medicaid covers Ozempic for type 2 diabetes with prior authorization on Medicaid.
Do you have to try metformin before Ozempic?
Yes for type 2 diabetes: Washington Medicaid requires a documented trial of metformin of at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication", "clinically_inappropriate"]).
How long does a Ozempic approval last with Washington Medicaid?
Initial approvals last 12 months, and renewals are granted in 12-month periods.
What does Washington Medicaid require to renew Ozempic?
Improvement in A1C and HbA1c ≤ 7 OR improved from baseline prior to GLP-1 treatment; diagnosis of T2DM confirmed; not used in combination with another GLP-1 agonist or DPP4 inhibitor. BMI and prior therapy step requirements are NOT re-verified at continuation.
How current is this information?
This page reflects Washington Medicaid's written policy as of June 1, 2026, last verified against the source document on June 4, 2026.

Other medications under Washington Medicaid

Ozempic coverage under other plans

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This page summarizes Washington Medicaid's written prior-authorization policy. It is not a guarantee of coverage; plans vary by employer and benefit design. Verify with your plan before relying on it.