Clover Health coverage for Ozempic (Kidney Disease (CKD))

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.

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