Employer / Commercial Insurance
Covered (preferred drug)
What you need to qualify
- Age 10 and older
- Diagnosis documented with a code
Qualification pathways
You can qualify through any one of these.
New patient - prior therapy requirement
All of:
- Diagnosis of type 2 diabetes mellitus (medical record documentation required)
- Requested product will not be taken concomitantly with a DPP-4 containing agent
- Requested product will not be taken concomitantly with another GLP-1 agonist
Plus any one of:
- Patient has tried and had an inadequate response, intolerance, or hypersensitivity to an agent containing metformin, sulfonylurea, or insulin
- Patient has an FDA labeled contraindication to metformin
- Patient has a diagnosis of, or is at high risk for, atherosclerotic cardiovascular disease, heart failure, chronic kidney disease, and/or MASH
Continuity of care - currently on therapy
All of:
- Diagnosis of type 2 diabetes mellitus (medical record documentation required)
- Prescriber states patient is currently being treated with the requested agent within the past 90 days and is at risk if therapy is changed
- Requested product will not be taken concomitantly with a DPP-4 containing agent
- Requested product will not be taken concomitantly with another GLP-1 agonist
Documentation to bring
- Medical record documentation of type 2 diabetes mellitus diagnosis
- Documentation of prior trial with inadequate response, intolerance, or hypersensitivity to metformin, sulfonylurea, or insulin OR FDA labeled contraindication to metformin OR diagnosis of/high risk for ASCVD, heart failure, CKD, or MASH (OR attestation that patient is currently on this agent within the past 90 days and at risk if changed)
- Attestation that requested product will not be taken concomitantly with a DPP-4 containing agent
- Attestation that requested product will not be taken concomitantly with another GLP-1 agonist
Quantity limits
- 2.5mg/0.5mL — 2 mL (4 pens)
- 5mg/0.5mL — 2 mL (4 pens)
- 7.5mg/0.5mL — 2 mL (4 pens)
- 10mg/0.5mL — 2 mL (4 pens)
- 12.5mg/0.5mL — 2 mL (4 pens)
- 15mg/0.5mL — 2 mL (4 pens)
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
Not covered when
- Concomitant use with DPP-4 containing agent
- Concomitant use with another GLP-1 agonist
Policy note: Mounjaro is listed as a preferred product per the April 2023 policy update. Indication expanded to include pediatric patients 10 years and older per Jan 2026 update. Approved for T2DM only per this policy; weight loss is not an approved indication under this policy document.
Policy effective May 1, 2026 · verified June 2, 2026 · source: glp1-agonists-nc-standard.pdf
Medicare Part D
Covered with requirements
What you need to qualify
- Diagnosis documented with a code
Qualification pathways
You can qualify through any one of these.
Existing patient — claim evidence of current use
All of:
- Medication will NOT be used for weight loss alone
- Patient has a diagnosis of type 2 diabetes mellitus
- Claim evidence shows patient is currently being treated with the requested medication within the past 180 days
- PA applies to new starts only (existing-use pathway exception)
Existing patient — prescriber attestation of current use
All of:
- Medication will NOT be used for weight loss alone
- Patient has a diagnosis of type 2 diabetes mellitus
- Prescriber states patient is currently being treated with the requested medication within the past 180 days
- PA applies to new starts only (existing-use pathway exception)
New start — prior non-GLP-1 oral diabetes medication requirement
All of:
- Medication will NOT be used for weight loss alone
- Patient has a diagnosis of type 2 diabetes mellitus
- Patient does NOT have any FDA labeled contraindications to the requested medication
- Patient will NOT be using the requested medication in combination with another GLP-1 agonist
- Patient will NOT be using the requested medication in combination with a DPP-4 inhibitor
Plus any one of:
- Medication history includes use of a non-GLP-1 oral diabetes medication (e.g., metformin, glipizide) within the past 90 days
- Patient had an ineffective treatment response to a non-GLP-1 oral diabetes medication
- Patient has an intolerance or hypersensitivity to a non-GLP-1 oral diabetes medication
- Patient has an FDA labeled contraindication to a non-GLP-1 oral diabetes medication
Documentation to bring
- Documentation of type 2 diabetes mellitus diagnosis
- Documentation that the medication will NOT be used for weight loss alone
- ONE of: claim history showing current use within past 180 days, OR prescriber attestation of current use within past 180 days, OR evidence of prior/current non-GLP-1 oral diabetes medication use within past 90 days OR documentation of ineffective response, intolerance, hypersensitivity, or FDA-labeled contraindication to non-GLP-1 oral diabetes medication
- Confirmation that patient has no FDA labeled contraindications to the requested medication (for new starts)
- Confirmation that patient will not use the medication in combination with another GLP-1 agonist (for new starts)
- Confirmation that patient will not use the medication in combination with a DPP-4 inhibitor (for new starts)
- If requesting quantity above program limit: prescriber-provided information supporting higher dose for the requested indication, and documentation that lower quantity of higher strength cannot achieve the requested dose
Approval and renewal
- Initial approval: 12 months
Not covered when
- Use for weight loss alone is excluded
- Combination use with another GLP-1 agonist or GLP-1-containing medication is excluded
- Combination use with a DPP-4 inhibitor or DPP-4-containing medication is excluded
- Use in patients with FDA labeled contraindications to the requested medication is excluded
Policy note: PA applies to new starts only. The policy lists oral diabetes medications broadly as acceptable step therapy alternatives to metformin, including: sulfonylureas, biguanides, meglitinide analogues, alpha-glucosidase inhibitors, DPP-4 inhibitors, bromocriptine, TZDs, SGLT2 inhibitors, and various combination products. Patients currently on the requested medication (within 180 days) qualify via claim history or prescriber attestation without needing to meet the prior oral diabetes medication requirement. Quantity limits apply per program; higher doses may be approved if a lower quantity of a higher strength cannot achieve the requested dose and prescriber provides clinical justification.
verified June 2, 2026 · source: GLP-1 Agonists – Bydureon, Mounjaro, Rybelsus Prior Authorization Criteria (with Quantity Limit) – Medicare Part D.pdf
Medicare Advantage
Covered with requirements
What you need to qualify
- Diagnosis documented with a code
Qualification pathways
You can qualify through any one of these.
Existing patient — claim evidence of current use
All of:
- Medication will NOT be used for weight loss alone
- Patient has a diagnosis of type 2 diabetes mellitus
- Claim evidence shows patient is currently being treated with the requested medication within the past 180 days
- PA applies to new starts only (existing-use pathway exception)
Existing patient — prescriber attestation of current use
All of:
- Medication will NOT be used for weight loss alone
- Patient has a diagnosis of type 2 diabetes mellitus
- Prescriber states patient is currently being treated with the requested medication within the past 180 days
- PA applies to new starts only (existing-use pathway exception)
New start — prior non-GLP-1 oral diabetes medication requirement
All of:
- Medication will NOT be used for weight loss alone
- Patient has a diagnosis of type 2 diabetes mellitus
- Patient does NOT have any FDA labeled contraindications to the requested medication
- Patient will NOT be using the requested medication in combination with another GLP-1 agonist
- Patient will NOT be using the requested medication in combination with a DPP-4 inhibitor
Plus any one of:
- Medication history includes use of a non-GLP-1 oral diabetes medication (e.g., metformin, glipizide) within the past 90 days
- Patient had an ineffective treatment response to a non-GLP-1 oral diabetes medication
- Patient has an intolerance or hypersensitivity to a non-GLP-1 oral diabetes medication
- Patient has an FDA labeled contraindication to a non-GLP-1 oral diabetes medication
Documentation to bring
- Documentation of type 2 diabetes mellitus diagnosis
- Documentation that the medication will NOT be used for weight loss alone
- ONE of: claim history showing current use within past 180 days, OR prescriber attestation of current use within past 180 days, OR evidence of prior/current non-GLP-1 oral diabetes medication use within past 90 days OR documentation of ineffective response, intolerance, hypersensitivity, or FDA-labeled contraindication to non-GLP-1 oral diabetes medication
- Confirmation that patient has no FDA labeled contraindications to the requested medication (for new starts)
- Confirmation that patient will not use the medication in combination with another GLP-1 agonist (for new starts)
- Confirmation that patient will not use the medication in combination with a DPP-4 inhibitor (for new starts)
- If requesting quantity above program limit: prescriber-provided information supporting higher dose for the requested indication, and documentation that lower quantity of higher strength cannot achieve the requested dose
Approval and renewal
- Initial approval: 12 months
Not covered when
- Use for weight loss alone is excluded
- Combination use with another GLP-1 agonist or GLP-1-containing medication is excluded
- Combination use with a DPP-4 inhibitor or DPP-4-containing medication is excluded
- Use in patients with FDA labeled contraindications to the requested medication is excluded
Policy note: PA applies to new starts only. The policy lists oral diabetes medications broadly as acceptable step therapy alternatives to metformin, including: sulfonylureas, biguanides, meglitinide analogues, alpha-glucosidase inhibitors, DPP-4 inhibitors, bromocriptine, TZDs, SGLT2 inhibitors, and various combination products. Patients currently on the requested medication (within 180 days) qualify via claim history or prescriber attestation without needing to meet the prior oral diabetes medication requirement. Quantity limits apply per program; higher doses may be approved if a lower quantity of a higher strength cannot achieve the requested dose and prescriber provides clinical justification.
verified June 2, 2026 · source: GLP-1 Agonists – Bydureon, Mounjaro, Rybelsus Prior Authorization Criteria (with Quantity Limit) – Medicare Part D.pdf
