UnitedHealthcare
Ozempic (0.25 or 0.5 MG/DOSE) (semaglutide)
Hormones : Drugs for Diabetes
  • Step Therapy: Diabetes Type 2: GLP1 + Combo:
    ST Single Generic

  • Quantity Limit: limit maximum 1.50 ML PER 28 day(s)
  • Prior Authorization: Diabetes Type 2: GLP1 + Combo:
    Documented Diagnosis: Yes
    Duration: 12 Month(s)

  • Diabetes Type 2: GLP1 + Combo:
    Duration: 12 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Supporting Documentation Requirements: Medication History