Applies to Employer and ACA Marketplace plans.
Covered (preferred drug)Qualification pathways
You can qualify through any one of these.
New Start — Preferred Agent
All of:
- Diagnosis of type 2 diabetes mellitus
- A1C ≥ 6.5% confirmed by lab test (lab results or medical records required)
- Mounjaro is a preferred agent — no step therapy required
- Age within FDA labeling for the requested indication OR support for use at patient's age
- Patient will NOT use requested agent in combination with a DPP-4 inhibitor
- Patient will NOT use requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications to Mounjaro
Continuation of Therapy
All of:
- Diagnosis of type 2 diabetes mellitus
- A1C ≥ 6.5% confirmed by lab test
- Mounjaro is listed as eligible for continuation of therapy
- Age within FDA labeling for the requested indication OR support for use at patient's age
- Patient will NOT use requested agent in combination with a DPP-4 inhibitor
- Patient will NOT use requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications to Mounjaro
Plus any one of:
- Patient has been treated with a preferred agent (not samples) within the past 90 days
- Prescriber states patient has been treated with a preferred agent within the past 90 days (not samples) and is at risk if therapy is discontinued
Documentation to bring
- Documentation of type 2 diabetes mellitus diagnosis
- Lab result confirming A1C ≥ 6.5% (or medical records)
- Attestation that patient will not use Mounjaro in combination with a DPP-4 inhibitor
- Attestation that patient will not use Mounjaro in combination with another GLP-1 receptor agonist
- Confirmation that patient has no FDA labeled contraindications to Mounjaro
- For continuation: documentation or prescriber statement of prior preferred agent use within past 90 days (samples not approvable)
Quantity limits
- 2.5 MG/0.5ML
- 5 MG/0.5ML, 7.5 MG/0.5ML, 10 MG/0.5ML, 12.5 MG/0.5ML, 15 MG/0.5ML — 4 pens
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
Not covered when
- Combination use with DPP-4 inhibitor agents (e.g., Januvia, Tradjenta, Onglyza, Nesina, Brynovin, Zituvio, and combination products)
- Combination use with another GLP-1 receptor agonist
- FDA labeled contraindications to Mounjaro (personal or family history of MTC or MEN2; prior serious hypersensitivity)
Policy note: Mounjaro is listed as a preferred agent. Non-preferred agents (Byetta, Exenatide, Victoza/liraglutide) require step therapy through two preferred agents or current stable therapy with positive outcome. Mounjaro (tirzepatide) intolerance/hypersensitivity/contraindication can be cited as one of the step therapy failures for non-preferred agents. The BCBS MN Step Therapy Supplement also applies to this program for all Commercial/HIM lines of business. Quantity limit: 4 pens per 28 days for maintenance doses; 2.5mg starter dose is 4 pens per 180 days.
Policy effective April 1, 2026 · verified June 5, 2026 · source: BCBS Minnesota ACA Marketplace prior authorization policy · View policy document (PDF)