Applies to Employer and ACA Marketplace plans.
Covered (preferred drug)Qualification pathways
You can qualify through any one of these.
Preferred GLP-1 - Prior Use within 90 Days
All of:
- Patient has diagnosis of type 2 diabetes mellitus
- Diagnosis confirmed by lab (A1C ≥ 6.5%)
- Age within FDA labeling for requested indication OR support provided for requested age
- Patient treated with a preferred agent within the past 90 days (samples not approvable)
- Will NOT be used in combination with a DPP-4 containing agent
- Will NOT be used in combination with another GLP-1 receptor agonist
- No FDA labeled contraindications to the requested agent
Preferred GLP-1 - New Start
All of:
- Patient has diagnosis of type 2 diabetes mellitus
- Diagnosis confirmed by lab (A1C ≥ 6.5%)
- Age within FDA labeling for requested indication OR support provided for requested age
- Mounjaro is a preferred GLP-1/GIP agent
- Will NOT be used in combination with a DPP-4 containing agent
- Will NOT be used in combination with another GLP-1 receptor agonist
- No FDA labeled contraindications to the requested agent
Documentation to bring
- Documentation of type 2 diabetes mellitus diagnosis
- Lab result confirming A1C ≥ 6.5%
- Documentation of patient age within FDA labeling OR clinical support for off-label age use
- Attestation that patient will not use in combination with a DPP-4 containing agent
- Attestation that patient will not use in combination with another GLP-1 receptor agonist
- Attestation of no FDA labeled contraindications to the requested agent
- If prior use pathway: documentation of prior preferred agent use within past 90 days (samples not acceptable)
Quantity limits
- 2.5mg/0.5mL, 5mg/0.5mL, 7.5mg/0.5mL, 10mg/0.5mL, 12.5mg/0.5mL, 15mg/0.5mL — 2 mL per month
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- Renewal: Patient must have had clinical benefit with the requested agent. No re-verification of T2DM diagnosis, A1C threshold, or step therapy at renewal.
Not covered when
- Combination use with DPP-4 containing agents
- Combination use with another GLP-1 receptor agonist
- FDA labeled contraindications to the requested agent
- Use for non-FDA approved indications (considered investigational unless excluded by contract)
Policy note: Mounjaro is a preferred agent. Step therapy through non-preferred agents is not required for preferred agents. For quantity limit exceptions: Mounjaro 2.5mg may be approved for maintenance therapy if patient has inability to use an FDA labeled maintenance strength AND has had clinical benefit at the lower strength. Policy notes metformin and insulin step therapy and comorbidity requirements were removed as of 04-01-2026 per Prime Trade agreement. Non-preferred GLP-1/GIP agents require trial/failure of TWO preferred agents (semaglutide, dulaglutide, or tirzepatide - 90 days each). Adlyxin noted in policy but is not listed as preferred or non-preferred in the formulary table.
Policy effective November 5, 2025 · verified June 2, 2026 · source: Policy 212 · View policy document (PDF)