Medicaid
Covered (preferred drug)What you need to qualify
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
Preferred agent — diagnosis-based authorization
All of:
- Diagnosis of Diabetes Mellitus Type II
Documentation to bring
- Documentation of Diabetes Mellitus Type II diagnosis
- Current A1C lab result (must be >= 7%)
Approval and renewal
- To renew, the plan looks for improvement in A1C and Re-authorization requires documentation of continued compliance on all diabetic therapies AND A1C must reach goal (A1C <= 8% OR demonstrated continued improvement).
Not covered when
- GLP-1 agents will NOT be approved in combination with a DPP-4 inhibitor
- Type 1 diabetes
Policy note: Ozempic is a PREFERRED agent in the GLP-1 Agonists class. As a preferred agent, PA is authorized with a diagnosis of Diabetes Mellitus Type II (no step therapy through other preferred agents required). The class-level non-preferred criteria (90-day compliance documentation, treatment failure with all preferred agents, A1C >= 7%) apply to non-preferred agents; the A1C >= 7% requirement and the DPP-4 inhibitor restriction appear to apply class-wide. Re-authorization requires continued compliance documentation and A1C <= 8% or continued improvement.
Policy effective January 1, 2026 · verified June 3, 2026 · source: download