| DRUG | COVERED | NOT COVERED |
|---|---|---|
| Ozempic | $25 | - |
| Mounjaro | $25 | $750 |
| Trulicity | $25 | - |
| Rybelsus | $10 | - |
| Wegovy | $0 | $600 |
| Zepbound | $25 | $750 |
| Risk Factor | Points |
|---|---|
| C - Congestive heart failure / LV dysfunction | 1 |
| H - Hypertension | 1 |
| A₂ – Age ≥ 75 years | 2 |
| D – Diabetes mellitus | 1 |
| S₂ – Stroke / TIA / thromboembolism | 2 |
| V – Vascular disease (MI, PAD, aortic plaque) | 1 |
| A – Age 65–74 years | 1 |
| Sc – Sex category (female) | 1 |