What does Clover Health require to renew Ozempic?

Type 2 Diabetes — Applies to Medicare Advantage plans. Therapy discontinuation should be considered if HbA1c is not at goal after 6 months of appropriate use or if patient has intolerable side effects. Implied continuation requires HbA1c to be at individualized goal. Heart Disease Risk Reduction — Applies to Medicare Advantage plans. Therapy discontinuation should be considered if HbA1c is not at goal after 6 months of appropriate use or if patient has intolerable side effects. Kidney Disease (CKD) — Applies to Medicare Advantage plans. Therapy discontinuation should be considered if HbA1c is not at goal after 6 months of appropriate use or if patient has intolerable side effects.

How current is this information?

The oldest review date among the policies on this page is April 1, 2026. Each policy's effective and verification dates appear with its requirements. Confirm current benefits with your plan.

Clover Health

Does Clover Health cover Ozempic?

Yes. Clover Health covers Ozempic for type 2 diabetes with prior authorization. Other policy requirements and your plan's benefits also apply.

Policy document

Clover Health Medicare Advantage prior authorization policy

Clover Health · PA policy · Medicare Advantage

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Medicare Advantage: Covered with requirements. See the qualification pathways below.

Earliest policy review April 1, 2026. How we verify · Check your exact plan

Full requirements: Ozempic for Type 2 Diabetes (1 plan type)

Applies to Medicare Advantage plans.

Covered with requirements

Qualification pathways

You can qualify through any one of these.

Route 1: Metformin trial/failure with T2DM diagnosis

All of:

Documented lifestyle modifications (nutrition therapy, physical activity, diabetes self-management) attempted
Confirmed T2DM diagnosis by one of: HbA1c ≥ 6.5%, fasting plasma glucose ≥ 126 mg/dL, or 2-hr plasma glucose ≥ 200 mg/dL during OGTT (with dates)
Trial of metformin at maximally tolerated dose for up to 3 months with HbA1c remaining above individualized target

Route 2: Metformin contraindication or intolerance with T2DM diagnosis

All of:

Documented lifestyle modifications (nutrition therapy, physical activity, diabetes self-management) attempted
Confirmed T2DM diagnosis by one of: HbA1c ≥ 6.5%, fasting plasma glucose ≥ 126 mg/dL, or 2-hr plasma glucose ≥ 200 mg/dL during OGTT (with dates)

Plus any one of:

Metformin intolerance (e.g., severe GI disturbances, lactic acidosis, B12 deficiency, hepatic injury, hypersensitivity reaction)
Metformin contraindication (e.g., eGFR < 30 mL/min/1.73m2, acute/chronic metabolic acidosis, known hypersensitivity to metformin, hepatic impairment, use of iodinated contrast media, excessive alcohol intake)

Documentation to bring

Documentation that lifestyle modifications (nutrition therapy, physical activity, diabetes self-management) have been attempted
Lab results confirming T2DM diagnosis: HbA1c ≥ 6.5%, OR fasting plasma glucose ≥ 126 mg/dL, OR 2-hr plasma glucose ≥ 200 mg/dL during OGTT (with dates for all labs)
Medical records showing metformin trial at maximally tolerated dose for up to 3 months with HbA1c remaining above individualized target, OR documentation of metformin intolerance or contraindication

Approval and renewal

Renewal: Therapy discontinuation should be considered if HbA1c is not at goal after 6 months of appropriate use or if patient has intolerable side effects. Implied continuation requires HbA1c to be at individualized goal.

Not covered when

History of medullary thyroid carcinoma (contraindication)
Multiple endocrine neoplasia type 2 / MEN2 (contraindication)
Weight loss/obesity as sole indication (excluded from Medicare Part D coverage)

Policy note: Policy explicitly states coverage for T2DM only. CMS excludes GLP-1 RAs prescribed solely for weight management/obesity from Medicare Part D coverage. Therapy discontinuation should be considered when HbA1c is not at goal after 6 months or when intolerable side effects occur. Monitoring includes HbA1c every 3-6 months, weight at each visit, annual renal function, GI side effects, hypoglycemia risk, pancreatitis/gallbladder signs, and diabetic retinopathy. The policy also references a separate Part D formulary and prior authorization criteria document at the Clover Health website.

source: Clover Health Medicare Advantage prior authorization policy · View policy document (PDF)

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Full requirements: Ozempic for Heart Disease Risk Reduction (1 plan type)

Applies to Medicare Advantage plans.

Covered with requirements

Qualification pathways

You can qualify through any one of these.

CV Risk Reduction in T2DM with established ASCVD

All of:

Documented lifestyle modifications (nutrition therapy, physical activity, diabetes self-management) attempted
Confirmed T2DM diagnosis by one of: HbA1c ≥ 6.5%, fasting plasma glucose ≥ 126 mg/dL, or 2-hr plasma glucose ≥ 200 mg/dL during OGTT (with dates)
Established atherosclerotic cardiovascular disease (ASCVD)

Plus any one of:

Documented history of myocardial infarction
Documented history of angina
Documented coronary artery stenosis
Documented history of stroke

Documentation to bring

Documentation that lifestyle modifications (nutrition therapy, physical activity, diabetes self-management) have been attempted
Lab results confirming T2DM diagnosis: HbA1c ≥ 6.5%, OR fasting plasma glucose ≥ 126 mg/dL, OR 2-hr plasma glucose ≥ 200 mg/dL during OGTT (with dates for all labs)
Medical records documenting established ASCVD (e.g., prior MI, angina, coronary artery stenosis, or stroke)

Approval and renewal

Renewal: Therapy discontinuation should be considered if HbA1c is not at goal after 6 months of appropriate use or if patient has intolerable side effects.

Not covered when

History of medullary thyroid carcinoma (contraindication)
Multiple endocrine neoplasia type 2 / MEN2 (contraindication)
Weight loss/obesity as sole indication (excluded from Medicare Part D coverage)

Policy note: CV risk reduction is listed as an alternative qualifying criterion (AND/OR) within the T2DM PA pathway. Patient still requires T2DM diagnosis and documented lifestyle modifications. This indication is presented as an additional pathway alongside metformin trial/failure, not as a standalone separate indication. The metformin trial is not explicitly required for this pathway per document language ('AND/OR').

source: Clover Health Medicare Advantage prior authorization policy · View policy document (PDF)

Open on its own page →

Full requirements: Ozempic for Kidney Disease (CKD) (1 plan type)

Applies to Medicare Advantage plans.

Covered with requirements

Qualification pathways

You can qualify through any one of these.

CKD with T2DM - renal and CV risk reduction

All of:

Documented lifestyle modifications (nutrition therapy, physical activity, diabetes self-management) attempted
Confirmed T2DM diagnosis by one of: HbA1c ≥ 6.5%, fasting plasma glucose ≥ 126 mg/dL, or 2-hr plasma glucose ≥ 200 mg/dL during OGTT (with dates)
Chronic kidney disease (CKD) with GFR < 60 mL/min/1.73 m2
Patient is on maximally tolerated dose of ACE inhibitor or ARB

Documentation to bring

Documentation that lifestyle modifications (nutrition therapy, physical activity, diabetes self-management) have been attempted
Lab results confirming T2DM diagnosis: HbA1c ≥ 6.5%, OR fasting plasma glucose ≥ 126 mg/dL, OR 2-hr plasma glucose ≥ 200 mg/dL during OGTT (with dates for all labs)
Lab result confirming CKD with GFR < 60 mL/min/1.73 m2
Documentation of current ACE inhibitor or ARB use at maximally tolerated dose

Approval and renewal

Renewal: Therapy discontinuation should be considered if HbA1c is not at goal after 6 months of appropriate use or if patient has intolerable side effects.

Not covered when

History of medullary thyroid carcinoma (contraindication)
Multiple endocrine neoplasia type 2 / MEN2 (contraindication)
Weight loss/obesity as sole indication (excluded from Medicare Part D coverage)

Policy note: CKD indication for Ozempic is listed within the T2DM PA pathway as an AND/OR qualifying criterion. Policy specifies 'reduction of risk of sustained eGFR decline, end-stage kidney disease and cardiovascular death in adults with T2DM.' Requires CKD (GFR < 60 mL/min/1.73 m2) on maximally tolerated dose of ACEi or ARB. This pathway does not explicitly require a metformin trial failure, as it is presented as an AND/OR alternative. No UACR threshold specified in this policy document.

source: Clover Health Medicare Advantage prior authorization policy · View policy document (PDF)

Open on its own page →

Questions people ask

Does Clover Health cover Ozempic?: Yes. Clover Health covers Ozempic for type 2 diabetes with prior authorization. Other policy requirements and your plan's benefits also apply.
What does Clover Health require to renew Ozempic?: Type 2 Diabetes — Applies to Medicare Advantage plans. Therapy discontinuation should be considered if HbA1c is not at goal after 6 months of appropriate use or if patient has intolerable side effects. Implied continuation requires HbA1c to be at individualized goal. Heart Disease Risk Reduction — Applies to Medicare Advantage plans. Therapy discontinuation should be considered if HbA1c is not at goal after 6 months of appropriate use or if patient has intolerable side effects. Kidney Disease (CKD) — Applies to Medicare Advantage plans. Therapy discontinuation should be considered if HbA1c is not at goal after 6 months of appropriate use or if patient has intolerable side effects.
How current is this information?: The oldest review date among the policies on this page is April 1, 2026. Each policy's effective and verification dates appear with its requirements. Confirm current benefits with your plan.

Also under Clover Health: Wegovy

Ozempic under other plans: Alabama Medicaid, Arkansas Medicaid, California Medicaid, Colorado Medicaid, Connecticut Medicaid, Delaware Medicaid, EmblemHealth, Fallon Health Plan

All insurance plans · All medications

Summary of Clover Health's written policy, not a guarantee of coverage. Plans vary by employer and benefit design.