The facts
Weight loss
Generally no
Type 2 diabetes
Yes, with PA (Smart PA) for type 2 diabetes
Prior auth
Required
Typical cost
Plan-specific
The criteria, as published
5 of 9 criteria are stated in the Ambetter (Centene) documents we read. Tap a row for the exact wording. Where a cell says not published, the documents we read do not say, and the line under it is how to find out.
- Formulary status
Tier 2 (preferred brand) with Smart PA on the 2026 Texas and Florida formularies
“OZEMPIC (0.25 OR 0.5 MG/DOSE) SOPN 2 Smart PA; QL(0.108 ML daily)”
ambetterhealth.com · 2026 plan year (updated October 2026)- BMI threshold
- Not published in what we readAsk member services for the written prior authorization criteria for Ozempic.
- Qualifying conditions
Type 2 diabetes diagnosis required
“A. Preferred GLP-1 RA Therapy* (must meet all): … 1. Diagnosis of type 2 diabetes mellitus; 2. Request is for liraglutide (Victoza), Mounjaro, Trulicity, Ozempic, Rybelsus, Soliqua, or Xultophy; 3. Requested product is not prescribed concurrently with another GLP-1 receptor agonist;”
ambetterhealth.com · 2026-09 (last review)- Lifestyle program
- Not published in what we readAsk whether a diet, exercise or behavioral program has to be documented, and for how long.
- Step therapy
None for preferred GLP-1s: must not be on another GLP-1
“A. Preferred GLP-1 RA Therapy* (must meet all): … 1. Diagnosis of type 2 diabetes mellitus; 2. Request is for liraglutide (Victoza), Mounjaro, Trulicity, Ozempic, Rybelsus, Soliqua, or Xultophy; 3. Requested product is not prescribed concurrently with another GLP-1 receptor agonist;”
ambetterhealth.com · 2026-09 (last review)- Quantity limit
0.108 mL daily
“OZEMPIC (0.25 OR 0.5 MG/DOSE) SOPN 2 Smart PA; QL(0.108 ML daily)”
ambetterhealth.com · 2026 plan year (updated October 2026)- Renewal
Renewed every 12 months if responding to therapy
“Approval duration: 12 months … II. Continued Therapy … 2. Member is responding positively to therapy;”
ambetterhealth.com · 2026-09 (last review)- Plan can exclude it?
- Not published in what we readAsk HR or member services whether your plan includes the weight-loss drug benefit.
- 2026 change
- Not published in what we readAsk whether Ozempic's status changed this year or changes at your next renewal.
Who actually decides this
Not the logo on your card, most of the time. Three parties sit between you and the answer, and knowing which one is saying no tells you who to ask.
- 1
The pharmacy benefit manager
No single PBM to name here, which is itself the finding. Different plans under this name use different benefit managers, so one national statement about the formulary would be wrong.
- 2
Your employer, if the plan comes through work
Weight-loss drugs are usually a category an employer buys or declines, not something the insurer includes by default. That is why two people holding identical cards get opposite answers, and why the useful question for member services is whether your plan includes the weight-loss medication benefit at all, before anything about criteria.
- 3
Your state or region
These plans are sold state by state, each with its own drug list, so the answer for one state does not carry to the next. Check the formulary for your state and plan year.
How prior authorization works here
Six steps. Specifics come from the criteria above; where Ambetter (Centene) does not publish one, the step says what to ask for.
- 1
Confirm the benefit exists
Before any paperwork, ask member services whether your plan covers Ozempic for weight management at all. A plan that excludes the category will refuse a perfect request.
- 2
Get the criteria in writing
Ask for the written prior authorization criteria for Ozempic, so your prescriber answers the plan's questions rather than guessing at them.
- 3
Your prescriber documents the clinical picture
Current and baseline BMI, with dates. Conditions: Type 2 diabetes diagnosis required. Records of any diet, exercise or behavioral program.
- 4
Answer step therapy, if there is any
What the documents say: None for preferred GLP-1s: must not be on another GLP-1. Still ask whether your own plan adds a step before Ozempic.
- 5
Submit, then track it
Your prescriber sends the plan’s form with the notes. Write down the date and the reference number, and ask how you will hear back.
- 6
Plan for the renewal
What the documents say: Renewed every 12 months if responding to therapy.
Get your real answer
Ask your doctor to send the prior authorization with your type 2 diabetes diagnosis. Check your exact copay for Tier 2 in Ambetter's Drug Cost tool for your plan.
Coverage is plan-specific: this page reports what Ambetter (Centene) publishes, not a promise about your plan. Not medical or insurance advice.
