Applies to Employer and ACA Marketplace plans.
Covered (preferred drug)Qualification pathways
You can qualify through any one of these.
Continuation of therapy (Mounjaro as preferred agent)
All of:
- Diagnosis of type 2 diabetes
- A1C ≥ 6.5% confirmed by lab test or medical records
- Patient is eligible for continuation of therapy: treated with a preferred agent within the past 90 days (starting on samples is not approvable), OR 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
- Patient age is within FDA labeling for the requested indication, OR there is support for using the requested agent for the patient's age
- Patient will NOT be using the requested agent in combination with a DPP-4 containing agent
- Patient will NOT be using the requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications to the requested agent
New start as preferred agent
All of:
- Diagnosis of type 2 diabetes
- A1C ≥ 6.5% confirmed by lab test or medical records
- Mounjaro is a preferred agent
- Patient age is within FDA labeling for the requested indication, OR there is support for using the requested agent for the patient's age
- Patient will NOT be using the requested agent in combination with a DPP-4 containing agent
- Patient will NOT be using the requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications to the requested agent
Documentation to bring
- Documentation of type 2 diabetes diagnosis
- Lab test results or medical records confirming A1C ≥ 6.5%
- For continuation: documentation of treatment with preferred agent within past 90 days (samples do not qualify)
- For non-preferred agent request: documentation of trials, intolerance, hypersensitivity, or contraindication to TWO of: semaglutide (Ozempic/Rybelsus), dulaglutide (Trulicity), tirzepatide (Mounjaro)
- Confirmation patient is not using a DPP-4 inhibitor concurrently
- Confirmation patient is not using another GLP-1 receptor agonist concurrently
Quantity limits
- 2.5 MG/0.5ML — 4 pens
- 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
- Concurrent use with DPP-4 inhibitor
- Concurrent use with another GLP-1 receptor agonist
- FDA labeled contraindications to the requested agent (personal or family history of MTC or MEN 2; prior serious hypersensitivity reaction)
Policy note: Mounjaro is listed as a preferred agent. For non-preferred agents, patient must have failed TWO of the three listed preferred agents (semaglutide, dulaglutide, or tirzepatide). For 2.5 mg: if used for maintenance therapy and quantity exceeds QL, patient must demonstrate inability to use an FDA labeled maintenance strength AND clinical benefit from the lower strength. Fill limit of one GLP-1 agent at one strength per 28 days applies across the class.
Policy effective May 11, 2026 · verified June 2, 2026 · source: Nd GLP-1 Paql Prog Sum · View policy document (PDF)