Medicaid coverage
Does New York Medicaid (NYRx) cover Rybelsus?
Rybelsus (semaglutide (oral)) for type 2 diabetes — the New York Medicaid (NYRx) prior-authorization rule, source-cited.
New York Medicaid (NYRx) Rybelsus PA criteria
Diabetes GLP-1 class is Clinical Criteria (CC).
Preferred (no PA if coverage parameters are in the member's Medicaid claim history at claim submission): exenatide, Ozempic pen, Trulicity, Victoza.
Non-preferred (PA required): Bydureon BCise, generic liraglutide, Mounjaro, Ozempic tablets, Rybelsus, Soliqua, Xultophy.
Criterion: confirm a diagnosis of an FDA-approved or compendia-supported AND Medicaid-covered indication; PA required for patients using a GLP-1 and a DPP-IV concurrently.
NO published A1C threshold and NO metformin step therapy.
Utilization edits: no more than one GLP-1 agonist or one strength at a time; titration/refill claims reject while >25% of the current fill remains.
Source: NYRx Drug Class Coverage Overview: GLP-1 Receptor Agonists - Type 2 Diabetes (Rev. 06/04/26) & NYRx PDL. View cited GLP-1 policy reference →
Frequently asked
- Does New York Medicaid (NYRx) cover Rybelsus for type 2 diabetes?
- Covered with prior authorization. Diabetes GLP-1 class is Clinical Criteria (CC). See the full source-cited criteria above. Per NYRx Drug Class Coverage Overview: GLP-1 Receptor Agonists - Type 2 Diabetes (Rev. 06/04/26) & NYRx PDL, as of 2026 (Coverage Overview & PDL Rev. 06/04/2026; doc dated 09/13/23) — 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 New York Medicaid (NYRx)-ready prior-authorization request with the right criteria and codes — free, no signup.