Is Mounjaro Covered by Insurance?

Whether Mounjaro is covered by your insurance depends almost entirely on your specific plan's rules, the reason it's being prescribed, and whether you meet strict medical criteria. While many plans cover Mounjaro for its FDA-approved use—type 2 diabetes—coverage for weight loss (an off-label use) is far less common. Understanding the processes of prior authorization and step therapy is key to unlocking potential coverage.

Key Takeaways

• Mounjaro usually requires prior authorization and step therapy, meaning your doctor must prove medical necessity and you may need to try other drugs first.
• Your cost is determined by its formulary tier; Mounjaro is often on a high specialty tier, leading to expensive coinsurance instead of a flat copay.
• Coverage differs drastically by diagnosis: Mounjaro for type 2 diabetes is more commonly covered, while Zepbound for weight loss is often excluded from plans.
• Always verify coverage directly with your insurer and pharmacy using your specific plan details to confirm cost and requirements.
• If coverage is denied, you have the right to appeal the decision, and working with your doctor on this step can often lead to approval.

Is Mounjaro Covered by Insurance, or Do I Need Prior Authorization First?

It is very likely you will need prior authorization before your insurance will approve coverage for Mounjaro. Prior authorization (PA) is a rule used by insurance companies where your doctor must get approval before they will agree to pay for a specific medication or treatment. This process ensures that the drug is being used for medically appropriate reasons according to the plan's guidelines.

For Mounjaro, this almost always means proving a diagnosis of type 2 diabetes and demonstrating that the medication is medically necessary for you. Insurance companies use this process to control costs and ensure patients receive effective, evidence-based care. Unfortunately, this necessary step can also lead to significant delays in treatment. A 2024 American Medical Association survey found that 24% of physicians reported prior authorization has led to serious adverse events for their patients .

If your insurance plan does cover Mounjaro, you will likely encounter one or both of these processes:

• Prior Authorization: Your doctor submits forms to your insurance company that provide clinical justification for why you need Mounjaro. This typically includes your diagnosis, medical history, and records of past treatments .
• Step Therapy: This is a specific type of prior authorization often called a "fail-first" protocol. Your insurance may require you to try and fail on one or more lower-cost, preferred medications—like metformin, Ozempic, or Trulicity—before they will approve coverage for Mounjaro.

What Formulary Tier Is Mounjaro On, and How Does It Affect My Copay Cost?

A formulary is your insurance plan's list of covered prescription drugs. Medications on this list are grouped into "tiers," which directly determine your out-of-pocket cost. Mounjaro is a specialty medication and is rarely placed on a low tier.

How Formulary Tiers Work

Mounjaro is almost always placed on a high specialty tier, often Tier 4 or Tier 5 . This means you will likely pay coinsurance instead of a flat copay. Coinsurance is a percentage of the drug's total cost, not a fixed amount. With Mounjaro's list price often over $1,000 per month, your share could be hundreds of dollars, especially if you haven't met your annual deductible .

Even with coverage, the cost can be high. This is where manufacturer savings cards can help. For eligible patients with commercial insurance, Eli Lilly offers a savings card that can bring the cost down to as little as $25 for a one-month prescription . It's important to note that these savings cards are typically only available for the medication's FDA-approved use, which for Mounjaro is type 2 diabetes .

Does Insurance Cover Mounjaro for Diabetes and Zepbound for Obesity Differently?

Yes, insurance treats Mounjaro and Zepbound very differently, and understanding this distinction is crucial. While they contain the exact same active ingredient, tirzepatide, they have different FDA approvals, and insurers create separate coverage pathways for each .

Mounjaro is FDA-approved for improving blood sugar control in adults with type 2 diabetes. Because of this, it is billed under a plan's diabetes medication benefits. Zepbound, however, is FDA-approved for chronic weight management and is billed under a plan's weight loss medication benefits, which are often more restricted .

Many insurance plans exclude weight loss medications entirely. This means even if you have a prescription for Zepbound, your plan might not cover it at all. For Mounjaro, if it is prescribed for weight loss (an "off-label" use), it is highly likely to be denied, as insurers typically only cover it for its approved diabetes indication .

This table highlights the key coverage differences:

What A1C, BMI, or Failed Therapy Requirements Are Needed for Mounjaro Insurance Coverage?

To get Mounjaro approved, your insurance company will require your doctor to submit specific clinical information proving medical necessity. While exact criteria vary by plan, they generally follow a common pattern focused on a type 2 diabetes diagnosis and documented treatment history.

The most common prior authorization criteria for Mounjaro include :

• Proof of Diagnosis: A confirmed diagnosis of type 2 diabetes, usually with a recent HbA1c level. While specific A1c targets vary by plan, the goal is often to show inadequate control on current therapies.
• Step Therapy History: Documentation that you have tried and failed to achieve glycemic control with one or more preferred, first-line medications. A common requirement is trying and failing two Step 1 medications, such as metformin, Ozempic (semaglutide), or Trulicity (dulaglutide) .
• Contraindications: If you cannot try a required medication due to a medical reason or side effects, your doctor must document this.

For Zepbound, which is approved for weight management, the criteria are different and often stricter. They typically require :

• BMI Requirement: A body mass index (BMI) of 30 or higher (obesity), or 27 or higher (overweight) with at least one weight-related comorbidity, such as high blood pressure, high cholesterol, or sleep apnea.
• Documented Weight Loss Attempts: Proof that you have attempted other weight loss methods in the past, such as supervised diet and exercise programs.

How Do I Check My Insurance Formulary and Verify Mounjaro Coverage With My Pharmacy Benefits?

Taking proactive steps to verify your own coverage can save you and your doctor time and help you avoid unexpected costs. You are your own best advocate in navigating your pharmacy benefits.

Here is a simple process to check your Mounjaro coverage:

1. Locate Your Plan's Formulary: This is usually a searchable PDF document available on your insurance company's member portal website. You can also call customer service to request one.
2. Search for Mounjaro: Once you have the formulary, search for "Mounjaro" or "tirzepatide." Note its tier placement and any "PA" or "ST" notations indicating prior authorization or step therapy requirements .
3. Call Your Insurance: The most direct way to get answers is to call the member services number on the back of your insurance card. Ask specific questions about coverage, cost-sharing, and process requirements .
4. Talk to Your Pharmacist: Your pharmacist can often run a "test claim" through your insurance to see if Mounjaro is covered and what your out-of-pocket cost would be before your doctor even sends in the prescription.

What Should I Ask When I Call My Insurance About Mounjaro Step Therapy or Quantity Limits?

Being prepared with the right questions will help you get the most out of a call to your insurance company. This script can guide your conversation and ensure you collect all the necessary information.

Insurance Verification Script

When you call, have your insurance card and a pen and paper ready.

• "Hello, I'd like to check the pharmacy benefits for my plan regarding the medication Mounjaro (tirzepatide)."
• "First, can you confirm if Mounjaro is on my plan's formulary?"
• "If it is covered, what tier is it on, and what will my out-of-pocket cost be? Is it a copay or coinsurance?"
• "Does my plan require prior authorization for Mounjaro?"
• "If yes, does my plan have step therapy requirements? Can you tell me what medications I need to try first?"
• "Are there any quantity limits or restrictions on how much Mounjaro I can get at one time?"
• "Is the prior authorization form available on your website? What is the process and timeline for my doctor to submit it?"
• "Finally, does my plan offer any savings card or copay assistance program that I can use with Mounjaro?"

What to Do Next

If your insurance denies your Mounjaro coverage, remember that you have the right to appeal the decision. According to data from several U.S. states, patients who file an internal appeal with their insurance provider see success rates between 39% and 59% . Denials are often issued automatically and don't consider your unique health situation. An appeal forces a real person, often a doctor, to review your case.

Start by working closely with your prescribing doctor. They can submit a "Letter of Medical Necessity" and provide the detailed clinical evidence needed to support your appeal. Be persistent, be prepared, and don't hesitate to fight for the treatment you and your doctor believe is best for your health.