Medicaid
Covered with requirementsWhat you need to qualify
- Diagnosis documented with a code
Qualification pathways
You can qualify through any one of these.
Type 2 diabetes — Code I diagnosis restriction must be met
All of:
- Type 2 diabetes diagnosis (Code I diagnosis restriction)
- Claim submitted with appropriate type 2 diabetes diagnosis code
Documentation to bring
- Appropriate type 2 diabetes ICD-10-CM diagnosis code on claim (Code I diagnosis restriction)
Policy note: Mounjaro remains on the CDL with a Code I diagnosis restriction of type 2 diabetes. Claims deny with Reject Code 80 when the Code I diagnosis restriction is not met. No longer eligible for weight loss or weight loss-related indications effective January 1, 2026. PA requests for non-weight-loss indications will be reviewed for medical necessity.
Policy effective April 6, 2026 · verified June 3, 2026 · source: 12_A_GLP-1_Coverage_Considerations.pdf