Commercial coverage
Does Humana cover Ozempic?
Ozempic (semaglutide) for type 2 diabetes — the Humana prior-authorization rule, source-cited.
Humana Ozempic PA criteria
Ozempic, Rybelsus, Mounjaro, Victoza covered for T2DM across plan types (Part D, MA-PD, commercial), generally Tier 3-4, WITH PA via Humana Pharmacy Solutions.
Per aggregator sources (NOT a Humana primary PDF), typical PA criteria: documented T2DM with ICD-10 (E11.xx); A1C >=7.0 (some pathways accept 6.5-6.9 with prior metformin trial); age >=18; step therapy with metformin first (documented trial/failure commonly required).
Reauth generally annual (continued control / A1C, adherence commonly MPR >=80%).
Off-label weight-loss use without T2DM denied.
Source: CMS Medicare GLP-1 Bridge demonstration & KFF BALANCE/Bridge explainer; Humana pharmacy policies (PBM: Humana Pharmacy Solutions, in-house). View cited GLP-1 policy reference →
Note: semaglutide is also sold as Wegovy for weight loss / obesity, which Humana evaluates under a separate weight loss / obesity policy (not this one) — see does Humana cover Wegovy?. Coverage follows the brand's FDA indication, not the molecule.
Frequently asked
- Does Humana cover Ozempic for type 2 diabetes?
- Covered with prior authorization. Ozempic, Rybelsus, Mounjaro, Victoza covered for T2DM across plan types (Part D, MA-PD, commercial), generally Tier 3-4, WITH PA via Humana Pharmacy Solutions. See the full source-cited criteria above. Per CMS Medicare GLP-1 Bridge demonstration & KFF BALANCE/Bridge explainer; Humana pharmacy policies (PBM: Humana Pharmacy Solutions, in-house), as of 2025-2026 (Zepbound OSA policy eff. 1/20/2025; Bridge 7/1/2026-12/31/2027; verified 2026-06-15) — confirm the member's current plan policy.
d3rx does not hold plan-specific pharmacy formularies or PBM prior-auth grids, so it cannot confirm a particular plan's GLP-1 coverage, tier, or PA criteria. The guidance below is the general, source-cited rule; confirm the specific plan's pharmacy formulary / PA policy for a binding answer.
Check Ozempic for another payer — or draft the PA
Run Ozempic + any payer in the GLP-1 PA lookup, or have Ask D3 draft a Humana-ready prior-authorization request with the right criteria and codes — free, no signup.