Do you have to try metformin before Ozempic?

Yes for type 2 diabetes: Clover Health requires a documented trial of metformin of at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication"]).

What does Clover Health require to renew Ozempic?

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.

Clover Health

Does Clover Health cover Ozempic?

Quick answer · Type 2 Diabetes

Clover Health covers Ozempic for type 2 diabetes with prior authorization on Medicare Advantage.

Medicare Advantage: Covered with requirements. A1C of 6.5% or higher

Source: Pa policy. How we verify this data →

Check your card for your exact plan →

Ozempic for Type 2 Diabetes

What Clover Health requires, by plan type. Open this indication on its own page →

Medicare Advantage

Covered with requirements

What you need to qualify

Age 18 and older
A1C of 6.5% or higher
6 months of a documented diet and exercise program
Trial of metformin for at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication"])
Lab results confirming eligibility

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

To renew, the plan looks for 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: Pa policy

Ozempic for Heart Disease Risk Reduction

What Clover Health requires, by plan type. Open this indication on its own page →

Medicare Advantage

Covered with requirements

What you need to qualify

Age 18 and older
A1C of 6.5% or higher
6 months of a documented diet and exercise program
Established cardiovascular disease (MI, angina, coronary_artery_stenosis, and stroke)
Lab results confirming eligibility

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

To renew, the plan looks for 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: Pa policy

Ozempic for Kidney Disease (CKD)

What Clover Health requires, by plan type. Open this indication on its own page →

Medicare Advantage

Covered with requirements

What you need to qualify

Age 18 and older
A1C of 6.5% or higher
6 months of a documented diet and exercise program
On guideline-directed medical therapy (ACE_inhibitor and ARB)
eGFR no higher than 60
Lab results confirming eligibility

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

To renew, the plan looks for 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: Pa policy

Why Ozempic requests get denied by Clover Health

Based on what this policy asks for. Fix these before the first submission.

Wrong brand for the diagnosis. Ozempic and Wegovy are the same molecule with different approved uses; a request for Ozempic under a diagnosis that matches Wegovy is routinely denied.
No recent A1C result on file.
No documented diet and exercise program.
No documented metformin trial (dose, dates, and outcome) or a stated reason it can't be used.

Frequently asked questions

Does Clover Health cover Ozempic?: Clover Health covers Ozempic for type 2 diabetes with prior authorization on Medicare Advantage.
Do you have to try metformin before Ozempic?: Yes for type 2 diabetes: Clover Health requires a documented trial of metformin of at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication"]).
What does Clover Health require to renew Ozempic?: 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.

Other medications under Clover Health

Does Clover Health cover Wegovy?

Ozempic coverage under other plans

All insurance plans · All medications

This page summarizes Clover Health's written prior-authorization policy. It is not a guarantee of coverage; plans vary by employer and benefit design. Verify with your plan before relying on it.