Applies to Employer and ACA Marketplace plans.
Covered (preferred drug)Qualification pathways
You can qualify through any one of these.
Auto-adjudication via claims history
All of:
- ICD-10 diagnosis code for type 2 diabetes mellitus present in member's medical claims history
Prior authorization — confirmed T2DM diagnosis
Plus any one of:
- History of A1C ≥ 6.5%
- History of 2-hour plasma glucose ≥ 200 mg/dL during OGTT
- History of symptoms of hyperglycemia (polyuria, polydipsia, polyphagia) or hyperglycemic crisis AND random plasma glucose ≥ 200 mg/dL
- History of fasting plasma glucose (FPG) ≥ 126 mg/dL
Documentation to bring
- Chart notes or medical record documentation supporting a diagnosis of type 2 diabetes mellitus (A1C > 6.5%, 2-hour plasma glucose ≥ 200 mg/dL during OGTT, symptoms of hyperglycemia with random plasma glucose ≥ 200 mg/dL, or fasting plasma glucose ≥ 126 mg/dL)
Quantity limits
- injection — all strengths — 1 pen/28 days
- tablet — all strengths — 30 tablets/30 days
Approval and renewal
- Initial approval: 12 months
Not covered when
- Weight reduction/management use is a standard exclusion for most benefits
Policy note: Ozempic (injection) is listed as a preferred product. Ozempic (tablet) is referenced alongside Rybelsus with the same labeling language. The policy uses a screen-out logic: if an ICD-10 code for T2DM is present in claims history, the drug is paid without PA. The FDA-approved indications for Ozempic include CV risk reduction in T2DM with established CVD and CKD, but the policy's coverage criteria only address T2DM and do not establish separate PA criteria for those indications — they are not addressed as standalone criteria in this document. The quantity limit is listed separately for injection (1 pen/28 days) and tablet (30 tablets/30 days).
Policy effective March 17, 2026 · verified June 3, 2026 · source: Antidiabetic GLP-1 Receptor Agonists And Gip GLP-1 Receptor Agonists · View policy document (PDF)