Applies to Employer and ACA Marketplace plans.
Covered (preferred drug)Qualification pathways
You can qualify through any one of these.
Continuation of therapy
All of:
- Diagnosis of type 2 diabetes mellitus
- A1C ≥ 6.5% confirmed by lab test (lab results or medical records required)
- Age within FDA labeling for indication OR support for off-label age use
- Will NOT use in combination with a DPP-4 containing agent
- Will NOT use in combination with another GLP-1 receptor agonist
- No FDA labeled contraindications to requested agent
Plus any one of:
- Patient has been treated with an eligible continuation agent (Ozempic, Rybelsus, Trulicity, Mounjaro, liraglutide, Bydureon BCise) within the past 90 days (not starting on samples)
- Prescriber states patient has been treated with an eligible continuation agent within the past 90 days (not starting on samples) AND patient is at risk if therapy is discontinued
New therapy - step therapy met
All of:
- Diagnosis of type 2 diabetes mellitus
- A1C ≥ 6.5% confirmed by lab test (lab results or medical records required)
- Age within FDA labeling for indication OR support for off-label age use
- Will NOT use in combination with a DPP-4 containing agent
- Will NOT use in combination with another GLP-1 receptor agonist
- No FDA labeled contraindications to requested agent
Plus any one of:
- Tried and had inadequate response to at least one prerequisite agent containing metformin or insulin
- Intolerance or hypersensitivity to metformin or insulin
- FDA labeled contraindication to BOTH metformin AND insulin
New therapy - CV risk reduction pathway
All of:
- Diagnosis of type 2 diabetes mellitus
- A1C ≥ 6.5% confirmed by lab test (lab results or medical records required)
- Patient has established cardiovascular disease (e.g., MI, stroke, any revascularization, TIA, unstable angina, amputation, symptomatic or asymptomatic CAD) OR multiple cardiovascular risk factors (e.g., hypertension, dyslipidemia, family history of CVD, smoking)
- Requested agent will be used to reduce the risk of major adverse cardiovascular events (CV death, non-fatal MI, or non-fatal stroke)
- Age within FDA labeling for indication OR support for off-label age use
- Will NOT use in combination with a DPP-4 containing agent
- Will NOT use in combination with another GLP-1 receptor agonist
- No FDA labeled contraindications to requested agent
New therapy - CKD pathway
All of:
- Diagnosis of type 2 diabetes mellitus
- A1C ≥ 6.5% confirmed by lab test (lab results or medical records required)
- Patient has chronic kidney disease (CKD)
- Requested agent will be used to reduce the risk of sustained eGFR decline, end-stage kidney disease, and cardiovascular death
- Age within FDA labeling for indication OR support for off-label age use
- Will NOT use in combination with a DPP-4 containing agent
- Will NOT use in combination with another GLP-1 receptor agonist
- No FDA labeled contraindications to requested agent
New therapy - MASH pathway
All of:
- Diagnosis of type 2 diabetes mellitus
- A1C ≥ 6.5% confirmed by lab test (lab results or medical records required)
- Patient has diagnosis of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH) with moderate to advanced liver fibrosis (F2 to F3)
- Age within FDA labeling for indication OR support for off-label age use
- Will NOT use in combination with a DPP-4 containing agent
- Will NOT use in combination with another GLP-1 receptor agonist
- No FDA labeled contraindications to requested agent
Documentation to bring
- Documentation of type 2 diabetes mellitus diagnosis
- Lab results confirming A1C ≥ 6.5% or medical records confirming diabetes diagnosis
- Documentation of metformin or insulin trial with inadequate response (≥90 days), OR documentation of intolerance/hypersensitivity/contraindication to metformin or insulin — OR documentation of qualifying CV disease/risk factors, CKD, or MASH with F2-F3 fibrosis — OR documentation of prior treatment with eligible continuation agent within past 90 days
- Confirmation patient will not use concurrently with a DPP-4 agent
- Confirmation patient will not use concurrently with another GLP-1 receptor agonist
- Confirmation of no FDA labeled contraindications to requested agent
Quantity limits
- 2.5 MG/0.5ML — 4 pens per 28 days
- 5 MG/0.5ML, 7.5 MG/0.5ML, 10 MG/0.5ML, 12.5 MG/0.5ML, 15 MG/0.5ML — 4 pens per 28 days
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- Renewal: Patient must have been treated with an eligible continuation agent within the past 90 days (starting on samples not approvable), OR prescriber states patient has been treated within the past 90 days and is at risk if therapy is discontinued.
Not covered when
- Concurrent use with DPP-4 containing agents (e.g., Januvia, Janumet, Onglyza, Tradjenta, etc.)
- Concurrent use with another GLP-1 receptor agonist
- Personal or family history of medullary thyroid carcinoma (MTC) or MEN 2 (per FDA contraindication)
- Prior serious hypersensitivity reaction to tirzepatide or product components
Policy note: Mounjaro is listed as a preferred/target agent. The policy applies to Commercial and HIM formularies. Fill limit of one GLP-1 agent and one strength per 28 days applies. For QL exceptions, Mounjaro 2.5 mg/0.5mL used for maintenance requires inability to use FDA-labeled maintenance strength AND documented clinical benefit from baseline. Length of approval is 12 months.
Policy effective May 25, 2026 · verified June 2, 2026 · source: Ri GLP-1 Agonists Paql Prog Sum · View policy document (PDF)