Centene coverage for Mounjaro (Type 2 Diabetes)

ACA Marketplace

Covered with requirements

What you need to qualify

Age 10 and older
Diagnosis documented with a code
Prior trial of 2 other GLP-1 medications (Victoza and Trulicity) for at least 90 days

Qualification pathways

You can qualify through any one of these.

T2DM with MASLD and overweight/obesity

All of:

Diagnosis of type 2 diabetes mellitus
Age >= 10 years
Diagnosis of MASLD
BMI 25-29.9 kg/m2 (overweight) or BMI >= 30 kg/m2 (obese)
Not prescribed concurrently with another GLP-1 receptor agonist or DPP-4 inhibitor
Dose does not exceed FDA-approved maximum (15 mg/week for adults, 10 mg/week for pediatrics)
Failure of both preferred GLP-1s: liraglutide (Victoza) for >= 3 consecutive months, then Trulicity for >= 3 consecutive months, unless clinically significant adverse effects, both contraindicated, or member has CKD and request is for Ozempic injection

T2DM with MASH

All of:

Diagnosis of type 2 diabetes mellitus
Age >= 10 years
Diagnosis of MASH
Failure of >= 3 consecutive month trial of pioglitazone unless contraindicated or clinically significant adverse effects
Not prescribed concurrently with another GLP-1 receptor agonist or DPP-4 inhibitor
Dose does not exceed FDA-approved maximum (15 mg/week for adults, 10 mg/week for pediatrics)
Failure of both preferred GLP-1s: liraglutide (Victoza) for >= 3 consecutive months, then Trulicity for >= 3 consecutive months, unless clinically significant adverse effects, both contraindicated, or member has CKD and request is for Ozempic injection

T2DM with ASCVD, high ASCVD risk, HFpEF, or CKD — agent with proven CV/renal benefit

All of:

Diagnosis of type 2 diabetes mellitus
Age >= 10 years
Mounjaro is an agent with proven cardiovascular benefit per 2026 ADA guidelines
Not prescribed concurrently with another GLP-1 receptor agonist or DPP-4 inhibitor
Dose does not exceed FDA-approved maximum (15 mg/week for adults, 10 mg/week for pediatrics)
Failure of both preferred GLP-1s: liraglutide (Victoza) for >= 3 consecutive months, then Trulicity for >= 3 consecutive months, unless clinically significant adverse effects, both contraindicated, or member has CKD and request is for Ozempic injection

Plus any one of:

Established atherosclerotic cardiovascular disease (ASCVD)
Indicators of high ASCVD risk (per Appendix D: age >= 55 with coronary/carotid/lower-extremity artery stenosis >50%, LVH, retinopathy, other end organ damage)
Heart failure with preserved ejection fraction
Chronic kidney disease
Failure of >= 3 consecutive months of SGLT2 inhibitor or SGLT2 inhibitor-containing product, unless clinically significant adverse effects or all contraindicated

T2DM without ASCVD, high ASCVD risk, HFpEF, CKD, MASLD, or MASH — non-GLP-1 step therapy

All of:

Diagnosis of type 2 diabetes mellitus
Age >= 10 years
No established ASCVD, indicators of high ASCVD risk, heart failure with preserved ejection fraction, CKD, MASLD, or MASH
Failure of >= 3 consecutive month trial of two agents from any of the following classes: biguanides, sulfonylureas, thiazolidinediones, DPP-4 inhibitors, SGLT2 inhibitors or SGLT2 inhibitor-containing products, unless clinically significant adverse effects or all contraindicated
Not prescribed concurrently with another GLP-1 receptor agonist or DPP-4 inhibitor
Dose does not exceed FDA-approved maximum (15 mg/week for adults, 10 mg/week for pediatrics)
Failure of both preferred GLP-1s: liraglutide (Victoza) for >= 3 consecutive months, then Trulicity for >= 3 consecutive months, unless clinically significant adverse effects, both contraindicated

Documentation to bring

Office chart notes, lab results, or other clinical information supporting all approval criteria
Documentation of type 2 diabetes mellitus diagnosis
Documentation of member age (>= 10 years)
Documentation of qualifying condition pathway (MASLD with overweight/obesity, MASH with pioglitazone trial/failure, ASCVD/high ASCVD risk/HFpEF/CKD with SGLT2i trial/failure, or two non-GLP-1 agent trial/failures)
Documentation of failure of liraglutide (Victoza) for >= 3 consecutive months (unless excepted)
Documentation of failure of Trulicity for >= 3 consecutive months after Victoza failure (unless excepted)
Confirmation that requested product is not prescribed concurrently with another GLP-1 receptor agonist or DPP-4 inhibitor

Approval and renewal

Initial approval: 12 months
Renewal: every 12 months
To renew, the plan looks for Member is responding positively to therapy. Continued therapy requires either (a) currently receiving medication via Centene benefit or previously met initial approval criteria, or (b) enrolled in a state with continuity of care regulations. No concurrent use with another GLP-1 or DPP-4 inhibitor.

Not covered when

Concurrent use with another GLP-1 receptor agonist
Concurrent use with a DPP-4 inhibitor
Dose exceeding FDA-approved maximum recommended dose
Type 1 diabetes

Policy note: Mounjaro is classified as a non-preferred GLP-1 receptor agonist requiring step therapy through liraglutide (Victoza) then Trulicity. Per 2026 ADA guidelines, Mounjaro was added as an agent with proven cardiovascular benefit. Age expansion to >= 10 years added per 2026 annual review. Mounjaro is a dual GLP-1/GIP receptor agonist but categorized under GLP-1 class policy. Pediatric maximum dose is 10 mg/week; adult maximum dose is 15 mg/week.

Policy effective February 26, 2026 · verified June 2, 2026 · source: CP.PMN.183.pdf