Applies to Employer plans.
Covered (preferred drug)Qualification pathways
You can qualify through any one of these.
Initial approval for T2DM
All of:
- Age ≥ 10 years
- Not being prescribed concurrently with another GLP-1 or GLP-1/GIP receptor agonist
- Diagnosis of Type 2 Diabetes Mellitus confirmed by lab or ICD-10 code
Plus any one of:
- History of antidiabetic medication use (insulin, sulfonylureas, metformin, SGLT-2 inhibitor, DPP-IV inhibitor, or other)
- History of intolerance, contraindication, clinically significant adverse effects, or inadequate response to metformin
Documentation to bring
- ICD-10 diagnosis code for Type 2 Diabetes Mellitus OR lab confirmation (HbA1C > 6.5%, FPG ≥ 126 mg/dL, 2-hour glucose ≥ 200 mg/dL on OGTT, or random glucose ≥ 200 mg/dL with classic hyperglycemia symptoms)
- Documentation or claims history of prior antidiabetic medication use OR documentation of metformin intolerance, contraindication, adverse effects, or inadequate response
Approval and renewal
- Initial approval: 12 months
Not covered when
- Concurrent use with another GLP-1 or GLP-1/GIP receptor agonist
- Type 1 diabetes
Policy note: Mounjaro is a Preferred drug subject to PA and Quality Care Dosing (quantity limits per policy #621B). Diagnosis confirmation requires at least one of: HbA1C > 6.5%, FPG ≥ 126 mg/dL, 2-hour plasma glucose ≥ 200 mg/dL on OGTT, random plasma glucose ≥ 200 mg/dL with classic symptoms, or documented ICD-10 code for T2DM. Step 4 criteria are per ADA and AACE/ACE guidelines. Policy applies to BCBSMA Commercial members; does NOT apply to Medicare Advantage. FDA age expansion to age 10 added in 5/2026 update.
Policy effective May 1, 2026 · verified June 2, 2026 · source: 056%20 Glucagon Like%20 Peptide 1%20(GLP-1)%20 Receptor%20 Agonists%20and%20 Related%20 Drugs%20for%20the%20 Treatment%20of%20 Type%202%20 Diabetes · View policy document (PDF)