Applies to Employer plans.
Covered (preferred drug)Qualification pathways
You can qualify through any one of these.
Initial approval — Preferred agent (Mounjaro)
All of:
- Diagnosis of type 2 diabetes
- Diagnosis confirmed by lab tests (e.g., A1C ≥ 6.5%); lab test results or medical records required
- Patient age is within FDA labeling for the requested indication, OR there is support for using the requested agent for the patient's age for the requested indication
- Patient will NOT use the requested agent in combination with a DPP-4 inhibitor
- Patient will NOT use the requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications to the requested agent
Continuation of therapy
All of:
- Diagnosis of type 2 diabetes
- Diagnosis confirmed by lab tests (e.g., A1C ≥ 6.5%); lab test results or medical records required
- Patient will NOT use the requested agent in combination with a DPP-4 inhibitor
- Patient will NOT use the requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications to the requested agent
Plus any one of:
- Patient has been treated with a preferred agent within the past 90 days (starting on samples is not approvable)
- Prescriber attests patient has been treated with a preferred agent within the past 90 days (starting on samples not approvable) AND patient is at risk if therapy with a preferred agent is discontinued
Documentation to bring
- Documentation of type 2 diabetes diagnosis
- Lab test results confirming diagnosis (e.g., A1C ≥ 6.5%) or supporting medical records
- Documentation that patient will not be using the agent in combination with a DPP-4 inhibitor
- Documentation that patient will not be using the agent in combination with another GLP-1 receptor agonist
- Confirmation that patient has no FDA labeled contraindications to the requested agent
- For continuation: documentation of prior treatment with a preferred agent within the past 90 days, or prescriber attestation with clinical rationale for why switching preferred agent poses risk
Quantity limits
- 2.5 MG/0.5ML — 4 pens
- 5 MG/0.5ML — 4 pens
- 7.5 MG/0.5ML — 4 pens
- 10 MG/0.5ML — 4 pens
- 12.5 MG/0.5ML — 4 pens
- 15 MG/0.5ML — 4 pens
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- Renewal: Continuation requires patient has been treated with a preferred agent within the past 90 days (starting on samples is not approvable); prescriber may attest patient has been treated with a preferred agent within 90 days and is at risk if therapy is discontinued.
Not covered when
- Combination use with DPP-4 inhibitor-containing agents
- Combination use with another GLP-1 receptor agonist
- FDA labeled contraindications to the requested agent (including personal or family history of MTC or MEN 2)
- Starting on samples is not approvable for continuation of therapy
Policy note: Policy applies to Capital Blue Cross Commercial, Small Group, Individual Exchange, CHIP, Net Results A, Net Results F. Mounjaro is listed as a preferred agent (CoT with Dx check module). For non-preferred agents, TWO step-therapy failures from a list including semaglutide (Ozempic/Rybelsus), dulaglutide (Trulicity), tirzepatide (Mounjaro), or documentation that prerequisite agents are not clinically appropriate are required. Fill limit: one GLP-1 agent and one strength per 28 days. Quantity limit exception available for Mounjaro 2.5 mg when intended for maintenance therapy if patient cannot use a labeled maintenance strength and has demonstrated clinical benefit. Pediatric patients 10 years and older are within FDA labeling.
Policy effective May 11, 2026 · verified June 5, 2026 · source: Capital BlueCross Employer / Commercial Insurance prior authorization policy · View policy document (PDF)