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
- A1C ≥ 6.5% confirmed by lab test
- Requested agent is eligible for continuation of therapy (Mounjaro is listed as eligible)
- No FDA labeled contraindications to the requested agent
- Not using in combination with a DPP-4 containing agent
- Not using in combination with another GLP-1 receptor agonist
Plus any one of:
- Patient has been treated with a preferred agent within the past 90 days (not starting on samples)
- Prescriber states patient has been treated with a preferred agent within the past 90 days and is at risk if therapy is discontinued
New therapy — step therapy failure or exception
All of:
- Diagnosis of type 2 diabetes
- A1C ≥ 6.5% confirmed by lab test
- No FDA labeled contraindications to the requested agent
- Not using in combination with a DPP-4 containing agent
- Not using in combination with another GLP-1 receptor agonist
- Patient age is within FDA labeling for the requested indication OR there is support for use at patient's age
Plus any one of:
- Tried and had inadequate response to ONE prerequisite agent containing metformin or insulin
- Intolerance or hypersensitivity to metformin or insulin
- FDA labeled contraindication to BOTH metformin AND insulin
- Patient has established cardiovascular disease (e.g., MI, stroke, revascularization, TIA, unstable angina, amputation, CAD) OR multiple CV risk factors (HTN, dyslipidemia, family history of CVD, smoking) AND requested agent will be used to reduce risk of MACE
- Patient has chronic kidney disease (CKD) AND requested agent will be used to reduce risk of sustained eGFR decline, ESKD, and cardiovascular death
- Patient has diagnosis of noncirrhotic MASH with moderate to advanced liver fibrosis (F2 to F3)
Documentation to bring
- Lab test confirming T2DM diagnosis (e.g., A1C ≥ 6.5%) or medical records
- Documentation of type 2 diabetes diagnosis
- Documentation of one of: inadequate response to metformin or insulin trial, intolerance/hypersensitivity to metformin or insulin, contraindication to both metformin and insulin, established CV disease or multiple CV risk factors, CKD diagnosis, or noncirrhotic MASH with F2-F3 fibrosis — OR documentation of prior preferred agent use within past 90 days for continuation
- Confirmation that patient will not use requested agent in combination with a DPP-4 containing agent
- Confirmation that patient will not use requested agent in combination with another GLP-1 receptor agonist
- If requesting Mounjaro 2.5 mg for maintenance therapy exceeding 180-day supply: documentation of inability to use an FDA labeled maintenance strength AND documentation of clinical benefit from the lower strength since baseline
Quantity limits
- 2.5 MG/0.5ML — 4 pens per 28 days; 4 pens per 180 days (titration dose — 180-day duration limit) (84-day)
- 5 MG/0.5ML — 4 pens per 28 days
- 7.5 MG/0.5ML — 4 pens per 28 days
- 10 MG/0.5ML — 4 pens per 28 days
- 12.5 MG/0.5ML — 4 pens per 28 days
- 15 MG/0.5ML — 4 pens per 28 days
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- Renewal: Patient has been 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 is discontinued. Initial A1C and step therapy requirements are not re-verified at continuation.
Not covered when
- Combination use with a DPP-4 containing agent for the requested indication
- Combination use with another GLP-1 receptor agonist
- Any FDA labeled contraindication to the requested agent
- Mounjaro 2.5 mg use beyond 180 days for maintenance therapy unless patient has inability to use an FDA labeled maintenance strength AND has had clinical benefit from lower dose
Policy note: Mounjaro is listed as a preferred agent on the WY NetR-Commercial Custom formulary. Fill limit of one GLP-1 agent and one strength per 28 days applies. The 2.5 mg strength has a 180-day supply duration (titration dose); exceptions for continued use beyond 180 days require inability to use a maintenance-strength dose AND documented clinical benefit. Quantity limit exceptions available for: switching strengths (inadequate response or intolerance), switching GLP-1 agents, agent lacking a maximum FDA labeled dose, or dose not achievable with lower quantity of higher strength. The step therapy requirement for non-preferred agents (Byetta, Exenatide, Victoza) requires two of the following trials: semaglutide (Ozempic/Rybelsus) 90-day trial failure/intolerance/contraindication, dulaglutide (Trulicity) 90-day trial failure/intolerance/contraindication, or tirzepatide (Mounjaro) 90-day trial failure/intolerance/contraindication — however Mounjaro is itself a preferred agent so this non-preferred step requirement does not apply to Mounjaro itself. Wegovy and Zepbound are listed in the 'not in combination with another GLP-1' exclusion list but are not otherwise covered or PA-criteria-established by this document.
Policy effective May 11, 2026 · verified June 4, 2026 · source: Wy GLP-1 Agonists Paql Prog Sum · View policy document (PDF)