Applies to Medicare Advantage plans.
Covered with requirementsQualification 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
- 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. 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: Clover Health Medicare Advantage prior authorization policy · View policy document (PDF)