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Does Clover Health cover Ozempic for Heart Disease Risk Reduction?

Yes. Clover Health covers Ozempic for heart disease risk reduction 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

    View PDF Download
  • 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 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)

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Questions people ask
Does Clover Health cover Ozempic?
Yes. Clover Health covers Ozempic for heart disease risk reduction with prior authorization. Other policy requirements and your plan's benefits also apply.
What does Clover Health require to renew Ozempic?
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.
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.