Medicaid
Covered with requirementsWhat 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