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WellSense Health Plan · Type 2 Diabetes

WellSense Health Plan coverage for Ozempic (Type 2 Diabetes)

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

  • Age 18 and older
  • Diagnosis documented with a code

Qualification pathways

You can qualify through any one of these.

Initial approval for Type 2 Diabetes

All of:

  • Diagnosis of Type 2 Diabetes Mellitus confirmed by documentation (medical records, chart notes, A1C, ICD-10 code)
  • Inadequate response within the past 130 days, adverse reaction, or contraindication to a formulary covered oral agent for T2DM (Appendix A)
  • Member is not using multiple GLP-1 agents
  • Member is at least 18 years of age

Reauthorization for Type 2 Diabetes

All of:

  • Diagnosis of Type 2 Diabetes Mellitus confirmed by documentation (medical records, chart notes, A1C, ICD-10 code)
  • Inadequate response, adverse reaction, or contraindication to a formulary covered oral agent for T2DM (Appendix A)
  • Member is not using multiple GLP-1 agents
  • Member is at least 18 years of age

Plus any one of:

  • Positive clinical response to therapy
  • Documentation of clinical justification to continue therapy with requested medication

Documentation to bring

  • Documentation confirming Type 2 Diabetes Mellitus diagnosis (medical records, chart notes, A1C result, or ICD-10 code)
  • Documentation of inadequate response within the past 130 days, adverse reaction, or contraindication to a formulary covered oral agent for T2DM (Appendix A)

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • To renew, the plan looks for Positive clinical response to therapy OR documentation of clinical justification to continue therapy with requested medication.

Not covered when

  • Member must not be using multiple GLP-1 agents simultaneously
  • Type 1 diabetes

Policy note: Covered use stated as 'all medically accepted indications unless otherwise excluded.' This document does not separately address Ozempic for CV risk reduction or CKD indications; those indications are not addressed and no explicit exclusion is stated. Step therapy requires inadequate response, adverse reaction, or contraindication to a formulary covered oral agent from Appendix A. The 130-day lookback period for oral agent trial applies to initial authorization only. Requirements may adjudicate at point of service if satisfied via automated record search.

Policy effective January 1, 2026 · verified June 10, 2026 · source: policy-445.html

ACA Marketplace

Covered with requirements

What you need to qualify

  • Age 18 and older
  • Diagnosis documented with a code

Qualification pathways

You can qualify through any one of these.

Initial approval for Type 2 Diabetes

All of:

  • Diagnosis of Type 2 Diabetes Mellitus confirmed by documentation (medical records, chart notes, A1C, ICD-10 code)
  • Inadequate response within the past 130 days, adverse reaction, or contraindication to a formulary covered oral agent for T2DM (Appendix A)
  • Member is not using multiple GLP-1 agents
  • Member is at least 18 years of age

Reauthorization for Type 2 Diabetes

All of:

  • Diagnosis of Type 2 Diabetes Mellitus confirmed by documentation (medical records, chart notes, A1C, ICD-10 code)
  • Inadequate response, adverse reaction, or contraindication to a formulary covered oral agent for T2DM (Appendix A)
  • Member is not using multiple GLP-1 agents
  • Member is at least 18 years of age

Plus any one of:

  • Positive clinical response to therapy
  • Documentation of clinical justification to continue therapy with requested medication

Documentation to bring

  • Documentation confirming Type 2 Diabetes Mellitus diagnosis (medical records, chart notes, A1C result, or ICD-10 code)
  • Documentation of inadequate response within the past 130 days, adverse reaction, or contraindication to a formulary covered oral agent for T2DM (Appendix A)

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • To renew, the plan looks for Positive clinical response to therapy OR documentation of clinical justification to continue therapy with requested medication.

Not covered when

  • Member must not be using multiple GLP-1 agents simultaneously
  • Type 1 diabetes

Policy note: Covered use stated as 'all medically accepted indications unless otherwise excluded.' This document does not separately address Ozempic for CV risk reduction or CKD indications; those indications are not addressed and no explicit exclusion is stated. Step therapy requires inadequate response, adverse reaction, or contraindication to a formulary covered oral agent from Appendix A. The 130-day lookback period for oral agent trial applies to initial authorization only. Requirements may adjudicate at point of service if satisfied via automated record search.

Policy effective January 1, 2026 · verified June 10, 2026 · source: policy-445.html

All Ozempic policies under WellSense Health Plan · Check your card