Clover Health coverage for Ozempic (Type 2

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

Clover Health coverage for Ozempic (Type 2 Diabetes)