Washington Medicaid coverage for Ozempic (Kidney Disease (CKD))

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.

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