Employer / Commercial Insurance
Covered (preferred drug)What you need to qualify
- Age 10 and older
- A1C of 6.5% or higher
- Trial of metformin for at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication"])
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
Standard T2DM with metformin failure or contraindication
All of:
- Age >= 10 years
- Diagnosis of type 2 diabetes
- Lab-verified diagnosis: A1C >= 6.5% OR FPG >= 126 mg/dL OR 2-hr plasma glucose >= 200 mg/dL on OGTT OR symptoms of hyperglycemia/crisis with random glucose >= 200 mg/dL
Plus any one of:
- Trial and inadequate response or intolerance to metformin (samples/coupons/discount cards excluded)
- Contraindication to metformin therapy
Documentation to bring
- Documentation of type 2 diabetes diagnosis
- Lab result confirming diagnosis: A1C >= 6.5%, OR fasting plasma glucose >= 126 mg/dL (after fasting >= 8 hours), OR 2-hour plasma glucose >= 200 mg/dL on 75g OGTT, OR random plasma glucose >= 200 mg/dL with symptoms of hyperglycemia/crisis
- Documentation of metformin trial with inadequate response or intolerance (samples/coupons/discount cards not accepted), OR documentation of metformin contraindication
Quantity limits
- all available strengths — 4 single dose pens/single dose vials per 28 days
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- To renew, the plan looks for At continuation, T2DM diagnosis and lab verification are re-verified. Metformin trial/contraindication requirement is NOT re-checked at continuation.
Not covered when
- Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
- Personal or family history of medullary thyroid carcinoma (MTC)
- Severe gastroparesis
- Prediabetes
- Obesity/weight loss indication
- Concomitant use with another GLP-1 receptor agonist (including Saxenda, Wegovy, Zepbound, Soliqua, or Xultophy)
- Concomitant use with a DPP-4 inhibitor
- Type 1 diabetes
Policy note: Mounjaro is listed as a preferred GIP/GLP-1 receptor agonist. Age minimum is 10 years. The ASCVD bypass to metformin step therapy is NOT listed for Mounjaro (unlike liraglutide-generic, Ozempic, Rybelsus, and Trulicity which have this bypass). Non-preferred agents require two preferred agent failures before approval.
Policy effective May 5, 2026 · verified June 2, 2026 · source: Download