Wisconsin Medicaid coverage for Ozempic (Type 2 Diabetes)

What you need to qualify

• A1C of 6.5% or higher
• Diagnosis documented with a code
• Prior trial of 2 other GLP-1 medications (preferred GLP-1 agents (at least 2)) for at least 90 days
• Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Completed and signed Prior Authorization Drug Attachment for Hypoglycemics, GLP-1 Agents (Form F-00238)
• Completed PA/RF (Prior Authorization Request Form, F-11018)
• Copy of member's current medical records documenting the medical condition being treated
• Details regarding previous GLP-1 medication use (at least 2 preferred GLP-1 agents trialed)
• Member's current treatment plan
• Member's current HbA1c lab report (within past 6 months)
• For step therapy failure pathway: HbA1c measured after member has been taking the maximum dose of a preferred agent for at least 3 consecutive months
• For adverse reaction pathway: documentation of clinically significant adverse drug reaction with preferred GLP-1 agent(s)

Approval and renewal

• Initial approval: 6 months
• Renewal: every 12 months
• To renew, the plan looks for improvement in A1C and Member must have been adherent with prescribed treatment regimen AND have a reduction in HbA1c compared to baseline prior to initiation of the non-preferred GLP-1 agent.

Not covered when

• Nonadherence to previous GLP-1 treatment is not valid criteria
• Member's fear of needles is not valid criteria
• Member's or prescriber's preference for an oral agent is not valid criteria
• Member's or prescriber's preference for the non-preferred GLP-1 agent is not valid criteria
• Member's or prescriber's preference for less frequent dosing schedule is not valid criteria
• Type 1 diabetes

Policy note: This is a Wisconsin ForwardHealth (Medicaid) policy. The document covers non-preferred GLP-1 agents as a class; preferred GLP-1 agents require only a valid diagnosis code on claims without a separate PA. The A1C >= 6.5% threshold applies only if the member is NOT currently on a GLP-1 agent; members already on a GLP-1 agent do not have a specific A1C threshold stated for switching. Initial PA approved for up to 183 days (~6 months); renewal approved up to 365 days. Step therapy requires trial and failure or adverse reaction with at least 2 preferred GLP-1 agents. The document does not name specific preferred vs. non-preferred agents; Ozempic is classified as non-preferred based on document context.

verified June 3, 2026 · source: Pa policy