Clover Health coverage for Ozempic (Heart Disease Risk Reduction)

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.

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