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Coverage rules

Pick a drug or a HCPCS Level II J-code and a state: Part D formulary coverage stats observed plus the Medicare NCD/LCD policy documents for that state's Medicare Administrative Contractor. Plan- and policy-level only.

Try Ozempic in TX · J0897 in TX. HCPCS Level II only; CPT codes are not served.

Ozempic · Semaglutide

Part D coverage in TX · CY2026 formulary files observed · national claims rank #36

Plans covering in TX
408 of 408
100.0%
Plans covering nationally
5,466 of 5,518
99.1%
Prior auth (TX, of covering)
•••
paid detail

Utilization management among TX plans that cover Ozempic (share of covering plans)

  • Tier 3 or lower
    TX
    •••
    National
    •••
  • Prior authorization
    TX
    •••
    National
    •••
  • Step therapy (plans)
    TX
    •••
    National
    •••
  • Quantity limit (plans)
    TX
    •••
    National
    •••
  • Enrollment covered
    TX
    •••
    National
    •••

Sign in free to see prior-auth and tier rates, step-therapy and quantity-limit counts, enrollment covered, and the per-plan table — Scout includes 5 full lookups a month, no card required.

Medicare Administrative Contractors for TX

  • A/B MAC (professional & facility): Novitas Solutions, Inc. (JH) 04411
  • DME MAC: CGS Administrators, LLC (J-C) 18003
  • Home health & hospice MAC: Palmetto GBA 11004

The DME MAC differs from the A/B MAC in every state; pick by claim type.

Not medical advice. This page describes insurance coverage data and policy documents. It is not medical, legal, or benefits advice, and it is not a recommendation to take, prescribe, or switch any medication. Talk to your doctor or pharmacist about treatment decisions.

Not a coverage guarantee. Coverage, tier, prior authorization, step therapy, and quantity-limit data are compiled from CMS public files and plan documents dated CY2026 CMS Part D Formulary PUF (C2 feed built 2026-08-27) and CMS Medicare Coverage Database exports as of 2026-08-21. Plans change formularies during the year and individual coverage depends on your specific plan, pharmacy, and coverage phase. Always verify with your plan's current formulary documents or by calling the number on your member ID card. Medicare beneficiaries can compare plans at Medicare.gov or 1-800-MEDICARE.

PBSwitch is a private company. We are not connected with or endorsed by the U.S. government, the federal Medicare program, or any insurance plan or drug manufacturer. Sources: CMS Part D Formulary & Plan Landscape PUF, CY2026. Methodology: compiled from the public source files cited above. Clinical review by a PharmD is in progress. Page updated 2026-10-22.

PBSwitch publishes plan- and policy-level data only. We hold no patient-level or claims-level identifiable data.