How to Get Insurance to Cover Mounjaro

Getting insurance to cover Mounjaro involves a process called prior authorization. You must prove medical necessity, often for Type 2 Diabetes, and show you've tried other medications first. Success requires careful documentation and persistence, with appeal success rates ranging from 39% to 59% if initially denied .

How to Get Insurance to Cover Mounjaro — What Does the Process Really Look Like?

Getting your Mounjaro prescription covered is a multi step process. You and your doctor must prove to your insurance company that this medication is medically necessary for you.

The process almost always starts with a prior authorization (PA). This is a formal request your doctor submits to your insurance plan. The request must demonstrate that you meet the plan's specific coverage criteria for Mounjaro . If your insurance approves the PA, you will only pay your standard copay. With a savings card, this can be as low as $25 for a one-month or three-month supply .

If the initial request is denied, do not lose hope. You have the right to appeal the decision. Studies show that between 39% and 59% of internal insurance appeals are successful . The key to navigating this process smoothly is being prepared, organized, and proactive.

What Should Be on My Mounjaro Insurance Checklist Before Submitting Prior Authorization?

Having the right documents ready before your doctor submits the prior authorization will significantly increase your chances of approval. Use this checklist to ensure you have everything you need.

Your Mounjaro Prior Authorization Documentation Checklist

• Confirmed Diagnosis: Ensure your medical record clearly states the condition being treated (e.g., Type 2 Diabetes) with the correct ICD-10 code .
• Current BMI and Date: Have your most recent height, weight, and Body Mass Index (BMI) recorded in your chart. Some plans require a specific BMI, especially for off-label use .
• Comorbidities List: Document all weight-related or diabetes-related health conditions, such as hypertension, high cholesterol, or sleep apnea, with their ICD-10 codes .
• Prior Medication History: Create a detailed list of other medications you have tried, such as metformin or other GLP-1 agonists. This is often called "step therapy" .
• Lifestyle Program Notes: Have your doctor note your participation in a reduced-calorie diet and increased physical activity. Mounjaro is indicated as an adjunct to these lifestyle changes .
• Dosage Information: Provide the exact dosage and prescribing schedule, including the NDC code for the specific Mounjaro strength prescribed .

Gathering this information upfront helps your doctor build a strong case for your treatment.

Do I Need Specific Diagnosis Codes or BMI Requirements for Insurance Coverage for Mounjaro?

Yes, specific diagnosis codes are critical, and BMI requirements may be a factor depending on your insurance plan's criteria.

Diagnosis Codes (ICD-10 Codes)

Mounjaro is FDA-approved for improving glycemic control in adults with Type 2 Diabetes mellitus . Therefore, insurance approval is most straightforward when you have a documented Type 2 Diabetes diagnosis.

Commonly used ICD-10 codes for Type 2 Diabetes include :

• E11.9: Type 2 diabetes mellitus without complications
• E11.65: Type 2 diabetes mellitus with hyperglycemia

While Mounjaro is sometimes prescribed off-label for weight loss, listing obesity as the primary diagnosis can lead to an automatic denial. If you are seeking treatment for weight management, ask your doctor about Zepbound (tirzepatide), which is the same medication but is FDA-approved for chronic weight management .

BMI and Comorbidities

For coverage of Zepbound for weight loss, or for Mounjaro under some plans, BMI is a key factor. The FDA-approved indication for Zepbound is for adults with :

• An initial BMI of 30 kg/m² or greater (obesity), or
• An initial BMI of 27 kg/m² or greater (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, dyslipidemia, type 2 diabetes mellitus, obstructive sleep apnea, or cardiovascular disease).

Documenting comorbidities that are caused by or related to your primary condition strengthens your case for medical necessity. Common comorbid diagnoses include :

• Hypertension (I10)
• High Cholesterol (E78.5)
• Obstructive sleep apnea (G47.33)

How to Write a Strong Mounjaro Medical Necessity Letter with Prior Therapies Included

A compelling Letter of Medical Necessity (LMN) is your doctor's opportunity to tell your story and build a logical argument for why Mounjaro is the right treatment for you. While your doctor will write the letter, understanding its components helps you provide them with the right information.

What to Include in a Medical Necessity Letter

A strong letter should include the following sections:

1. Patient Information and Diagnosis: Start with your basic details and a clear statement of your primary diagnosis (e.g., Type 2 Diabetes) and any relevant comorbidities .
2. Detailed Treatment History (Step Therapy): This is a crucial section. List all previous medications you have tried and failed, often including metformin, sulfonylureas, or other GLP-1 receptor agonists. For each medication, note the duration of treatment and why it was discontinued (e.g., "ineffective at controlling A1c" or "side effects of nausea and vomiting were intolerable") .
3. Current Health Status and Lab Results: Include objective data like your most recent A1c level, fasting glucose numbers, and current BMI. This provides a baseline to measure future progress against .
4. Lifestyle Modifications: State that you are committed to using Mounjaro as an "adjunct to a reduced-calorie diet and increased physical activity." Your doctor should confirm your participation in these lifestyle changes .
5. Clinical Rationale for Mounjaro: The letter should explain why Mounjaro is the best choice for you compared to other alternatives, based on your clinical history and the drug's efficacy profile .

Sample Letter Structure:

[Doctor’s Letterhead]

[Date]

To: [Insurance Company Name] Re: Letter of Medical Necessity for [Patient Name], DOB: [Date of Birth], Member ID: [ID Number]

Dear Prior Authorization Department,

I am writing to advocate for the approval of Mounjaro (tirzepatide) for my patient, [Patient Name]. [Patient Name] has been diagnosed with Type 2 Diabetes (ICD-10 code E11.9) and has comorbid conditions including hypertension (I10) and hyperlipidemia (E78.5).

Despite lifestyle interventions, [Patient Name]'s diabetes remains uncontrolled, with a current A1c of [A1c Value]. We have pursued an extensive trial of alternative therapies, including:

• Metformin: Tolerated for 6 months but resulted in insufficient glycemic control.
• [Other medication]: Discontinued due to [reason, e.g., adverse side effects or lack of efficacy].

[Patient Name] is actively engaged in a reduced-calorie diet and a consistent physical activity program. Given their treatment-resistant profile and the need for more effective glycemic control, Mounjaro is medically necessary. We request your approval for this treatment.

Sincerely, [Doctor’s Name and Signature]

What Happens If Insurance Denies Mounjaro — Understanding the Appeal Levels

A denial is not the final word. You have the right to appeal, and understanding the different levels of appeal is key to continuing your fight for coverage.

First-Level Appeal (Internal Appeal)

This is your first formal request for the insurance company to reconsider its initial denial. You typically have 180 days from the date of the denial letter to submit this appeal . Your appeal letter should directly address the specific reason for denial provided by your insurance.

• If denied for "Missing Type 2 Diabetes Diagnosis": Provide additional lab reports and doctor's notes that solidify the diagnosis .
• If denied for "Step Therapy": Further elaborate on why the required medications are not suitable for you, providing more detail on side effects or ineffectiveness .
• If denied because "Mounjaro isn't on formulary": Specifically request a "formulary exception" based on medical necessity .

Second-Level Appeal (Internal Reconsideration)

If the first appeal is denied, the next step is often a second-level internal review. This may be reviewed by a different medical director or a panel at the insurance company. At this stage, you can include additional supporting documents, such as new lab results or a letter from a specialist.

External Appeal

After exhausting the insurance company's internal appeals process, you can request an independent external review. This means a third-party, independent organization that is not connected to your insurance company will review your case and make a binding decision. Your insurance company is required to provide you with information on how to request an external review after your final internal denial.

How Do I Use a Phone Script and Handle Pharmacy Rejections or Formulary Alternatives for Mounjaro?

Being prepared for conversations with your insurer and knowing how to handle pharmacy issues are the final steps to accessing your medication.

Phone Script for Calling Your Insurer

Being prepared makes these calls more effective. Have your Member ID, prescription details, and any denial letters in front of you.

Sample Script: "Hello, I'm calling to understand the coverage criteria for Mounjaro (tirzepatide) under my plan, [Your Member ID]. Can you please tell me:

1. Is Mounjaro on my plan's drug formulary?
2. If so, what are the specific prior authorization criteria for it?
3. Could you also please provide the prior authorization criteria for Ozempic?
4. What is the process for submitting an appeal if a claim is denied?"

This script helps you gather the exact information you need to guide your doctor and prepare for potential hurdles .

Handling Pharmacy Rejections

Sometimes, even with an approved PA, the pharmacy may encounter issues.

• NDC Code Mismatch: Ensure the pharmacy is using the correct National Drug Code (NDC) for your specific Mounjaro dosage. These codes are unique to each strength .
• Quantity Limits: Your insurance may have limits on how much medication you can get at once. If you have a prescription for a 3-month supply but the plan only covers 1-month, you may need to ask your doctor to adjust the prescription or for your insurer to make an exception .
• Pharmacy Doesn't Have Supply: If your pharmacy is out of stock, remember they often restock daily. You can ask them to order it or transfer the prescription to another in-network pharmacy that has it in stock .

Formulary Alternatives

If Mounjaro is not covered, ask your insurer or doctor about formulary alternatives. These are "preferred" drugs that work similarly.

• Common GLP-1 alternatives that your plan might prefer include Ozempic (semaglutide), Rybelsus (oral semaglutide), or Victoza (liraglutide) .
• If you are using Mounjaro for weight management, ask your doctor about submitting a PA for Zepbound, which is the same active ingredient (tirzepatide) but is approved specifically for chronic weight management .

What to Do Next / When to Seek Help

Start by calling your insurance provider to get their specific PA criteria. Then, schedule an appointment with your doctor to review the checklist and compile all necessary documentation. Being an organized and informed advocate for your own health is the most powerful tool you have.

If you feel overwhelmed by the process, especially if you have received a denial, consider seeking help. There are patient advocacy services, like Honest Care mentioned in the search results, that specialize in helping patients write appeal letters and fight insurance denials for medications like Mounjaro.

Reference: https://www.findhonestcare.com/blog-posts/prior-authorization-for-mounjaro