Commercial coverage
Does Anthem (Elevance Health) cover Rybelsus?
Rybelsus (semaglutide (oral)) for type 2 diabetes — the Anthem (Elevance Health) prior-authorization rule, source-cited.
Anthem (Elevance Health) Rybelsus PA criteria
Diabetes GLP-1s covered with PA.
Seven drugs (Ozempic, Rybelsus, Mounjaro, Victoza, Byetta, Bydureon, Trulicity) carry a Code I type 2 diabetes diagnosis restriction; claims deny with Reject Code 80 when the restriction is not met (Trulicity restriction effective 1/1/2026).
Commercial CarelonRx specifics (A1C >=7.0% and metformin step therapy) are corroborated only by secondary sources (medium-confidence, no retrievable Anthem primary doc).
Wegovy/Zepbound/Saxenda removed from CDL for weight loss eff. 1/1/2026; Wegovy retained for MASH/CV, Zepbound for OSA.
Source: Anthem HealthKeepers Plus VA Medicaid Weight Loss PA Form (VABCBS-CD-091232-25, Oct 2025) & Anthem CA diabetes Code I doc (CA-BC-CD-001363-25-S604, Nov 2025). View cited GLP-1 policy reference →
Frequently asked
- Does Anthem (Elevance Health) cover Rybelsus for type 2 diabetes?
- Covered with prior authorization. Diabetes GLP-1s covered with PA. See the full source-cited criteria above. Per Anthem HealthKeepers Plus VA Medicaid Weight Loss PA Form (VABCBS-CD-091232-25, Oct 2025) & Anthem CA diabetes Code I doc (CA-BC-CD-001363-25-S604, Nov 2025), as of 2025 (WL form Oct 2025; CA diabetes doc Nov 14 2025; Trulicity Code I eff. 1/1/2026; WL CDL removal eff. 1/1/2026) — 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 Rybelsus for another payer — or draft the PA
Run Rybelsus + any payer in the GLP-1 PA lookup, or have Ask D3 draft a Anthem (Elevance Health)-ready prior-authorization request with the right criteria and codes — free, no signup.