Applies to Employer and ACA Marketplace plans.
Covered (preferred drug)Qualification pathways
You can qualify through any one of these.
Continuation of therapy
All of:
- Diagnosis of type 2 diabetes
- A1C ≥ 6.5% confirmed by lab test or medical records
- Requested agent is eligible for continuation of therapy (Mounjaro is eligible)
- Patient will NOT use requested agent in combination with a DPP-4 containing agent
- Patient will NOT use requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications to the requested agent
- Patient age is within FDA labeling OR there is support for use outside labeled age range
Plus any one of:
- Patient has been treated with a preferred agent within the past 90 days (starting on samples is not approvable)
- Prescriber states patient has been treated with a preferred agent within the past 90 days and is at risk if therapy with a preferred agent is discontinued
New therapy - metformin/insulin step therapy or exception
All of:
- Diagnosis of type 2 diabetes
- A1C ≥ 6.5% confirmed by lab test or medical records
- Patient will NOT use requested agent in combination with a DPP-4 containing agent
- Patient will NOT use requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications to the requested agent
- Patient age is within FDA labeling OR there is support for use outside labeled age range
Plus any one of:
- Tried and had an inadequate response to ONE prerequisite agent containing metformin or insulin
- Intolerance or hypersensitivity to metformin or insulin
- FDA labeled contraindication to BOTH metformin AND insulin
CV risk reduction pathway
All of:
- Diagnosis of type 2 diabetes
- A1C ≥ 6.5% confirmed by lab test or medical records
- Patient has established cardiovascular disease (e.g., MI, stroke, revascularization, TIA, unstable angina, amputation, symptomatic or asymptomatic CAD) OR multiple cardiovascular risk factors (e.g., HTN, dyslipidemia, family history of CVD, smoking)
- Requested agent will be used to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal MI, or non-fatal stroke)
- Patient will NOT use requested agent in combination with a DPP-4 containing agent
- Patient will NOT use requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications to the requested agent
- Patient age is within FDA labeling OR there is support for use outside labeled age range
CKD pathway
All of:
- Diagnosis of type 2 diabetes
- A1C ≥ 6.5% confirmed by lab test or medical records
- Patient has chronic kidney disease (CKD)
- Requested agent will be used to reduce the risk of sustained eGFR decline, end-stage kidney disease, and cardiovascular death
- Patient will NOT use requested agent in combination with a DPP-4 containing agent
- Patient will NOT use requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications to the requested agent
- Patient age is within FDA labeling OR there is support for use outside labeled age range
MASH pathway
All of:
- Diagnosis of type 2 diabetes
- A1C ≥ 6.5% confirmed by lab test or medical records
- Patient has diagnosis of noncirrhotic MASH with moderate to advanced liver fibrosis (stages F2 to F3)
- Patient will NOT use requested agent in combination with a DPP-4 containing agent
- Patient will NOT use requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications to the requested agent
- Patient age is within FDA labeling OR there is support for use outside labeled age range
Documentation to bring
- Documentation of type 2 diabetes diagnosis
- Lab test results or medical records confirming A1C ≥ 6.5%
- Documentation of prior preferred agent use within past 90 days (for continuation pathway)
- Documentation of inadequate response to, intolerance of, hypersensitivity to, or contraindication to metformin or insulin (for new therapy pathway where applicable)
- Documentation of established CVD or multiple CV risk factors if using CV pathway
- Documentation of CKD diagnosis if using CKD pathway
- Documentation of noncirrhotic MASH with F2-F3 fibrosis if using MASH pathway
- Confirmation that patient will not use with DPP-4 containing agent
- Confirmation that patient will not use with another GLP-1 receptor agonist
Quantity limits
- 2.5 MG/0.5ML — 4 pens per 28 days
- 5 MG/0.5ML, 7.5 MG/0.5ML, 10 MG/0.5ML, 12.5 MG/0.5ML, 15 MG/0.5ML — 4 pens per 28 days
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- Renewal: Continuation of therapy is available if the patient has been treated with a preferred agent within the past 90 days (starting on samples is not approvable) OR the prescriber states the patient has been treated with a preferred agent within the past 90 days and is at risk if therapy with a preferred agent is discontinued.
Not covered when
- Combination with DPP-4 containing agents not permitted
- Combination with another GLP-1 receptor agonist not permitted
- FDA labeled contraindications to the requested agent
- Personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
- Prior serious hypersensitivity reaction to tirzepatide or product components
Policy note: Mounjaro is listed as a preferred agent. The 2.5 mg/0.5 mL strength has a 180-day duration limit noted in the QL table (likely titration dose). Non-preferred agents (Byetta, Victoza) require trial of TWO preferred agents before approval. Fill limit of one GLP-1 agent and one strength per 28 days applies. Pediatric patients aged 10 years and older are included per FDA labeling.
Policy effective May 11, 2026 · verified June 2, 2026 · source: Ks GLP-1 Prog Sum · View policy document (PDF)