Medicaid
Covered with requirementsWhat you need to qualify
- Diagnosis documented with a code
Qualification pathways
You can qualify through any one of these.
Initial approval for T2DM
All of:
- Diagnosis of type 2 diabetes mellitus (T2DM) with ICD-10 code provided
- FDA-approved indication for the requested GLP-1 agonist
- Dosage, frequency, and age within FDA-approved range
- No contraindicated conditions or diseases with GLP-1 agonist therapy
- Member is not currently on another GLP-1 agonist
Non-preferred agent request
All of:
- All initial approval criteria met
- Preferred GLP-1 agents have been tried and results documented in medical records
Documentation to bring
- Member's relevant medical records and/or pharmacy profile
- Appropriate baseline diagnostic and safety laboratory and/or noninvasive test results
- ICD-10 diagnosis code for T2DM
- Pharmacy claims history or pharmacy profile
- Documentation that dosage, frequency, and age are within FDA-approved range
- Documentation that member has no contraindicated conditions/diseases with GLP-1 agonist therapy
- Documentation that member is not currently on another GLP-1 agonist
- If brand name is medically necessary: MedWatch Form 3500
- If non-preferred agent: documentation that preferred medications have been utilized with results
Quantity limits
- all strengths — ≤30-day supply (initial and dose-change re-authorization); ≤90-day supply (re-authorization with no dose change) (84-day)
Approval and renewal
- Initial approval: 6 months
- To renew, the plan looks for Provider must document reason for dose change (titrating) or no dose change (maintenance). Change in dose: approval up to 1 month in <=30-day supplies. No change in dose: approval up to 6 months in <=90-day supplies.
Not covered when
- Contraindicated conditions or diseases with GLP-1 agonist therapy
- Currently on another GLP-1 agonist
- Off-label/unapproved indications without two peer-reviewed articles demonstrating safety and efficacy
Policy note: This is a Delaware Medicaid (DMAP) PA request form for GLP-1 agonists for T2DM. The policy is class-level (all GLP-1 agonists for T2DM) and does not specify individual brand criteria. Mounjaro is included as an in-scope GLP-1 agonist FDA-approved for T2DM. Initial authorization is for a 6-month trial dispensed in ≤30-day supplies. Re-authorization: dose change = up to 1 month in ≤30-day supplies; no dose change = up to 6 months in ≤90-day supplies. Preferred vs. non-preferred distinction exists but specific preferred agents are not listed in this document. Brand name medical necessity requires MedWatch Form 3500.
Policy effective April 20, 2026 · verified June 4, 2026 · source: Pa policy