Employer / Commercial Insurance
Covered (preferred drug)No additional clinical requirements are listed beyond the diagnosis.
Qualification pathways
You can qualify through any one of these.
Continuation of therapy (Mounjaro as preferred)
All of:
- Diagnosis of type 2 diabetes mellitus (medical record documentation required)
- Mounjaro is eligible for continuation of therapy
- Patient will NOT use requested agent in combination with a DPP-4 containing agent
- Patient will NOT use requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications to the requested agent
- Request is NOT for weight loss (weight loss is a benefit exclusion)
Plus any one of:
- Patient has been treated with a preferred agent within the past 90 days (starting on samples is not approvable)
- Prescriber states patient has been treated with a preferred agent within the past 90 days and patient is at risk if therapy with a preferred agent is discontinued
New/initial therapy as preferred agent
All of:
- Diagnosis of type 2 diabetes mellitus (medical record documentation required)
- Requested agent is a preferred agent (Mounjaro qualifies)
- Patient's age is within FDA labeling for the requested indication OR there is support for using the requested agent for the patient's age
- Patient will NOT use requested agent in combination with a DPP-4 containing agent
- Patient will NOT use requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications to the requested agent
- Request is NOT for weight loss (weight loss is a benefit exclusion)
Documentation to bring
- Medical record documentation of type 2 diabetes mellitus diagnosis
- If continuation: documentation of prior preferred agent use within past 90 days (paid claim from another health plan within past 90 days is acceptable alternative to step therapy requirement)
- If non-preferred step therapy: medical record documentation of intolerance/contraindication to preferred agents (two of: semaglutide, dulaglutide, tirzepatide)
- Documentation that patient will not be using agent in combination with a DPP-4 inhibitor
- Documentation that patient will not be using agent in combination with another GLP-1 receptor agonist
- Confirmation that request is not for weight loss
Quantity limits
- 2.5 mg/0.5 mL — 4 pens
- 5 mg/0.5 mL, 7.5 mg/0.5 mL, 10 mg/0.5 mL, 12.5 mg/0.5 mL, 15 mg/0.5 mL — 4 pens
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- To renew, the plan looks for Eligible for continuation if patient has been treated with a preferred agent (Ozempic, Rybelsus, Trulicity, Mounjaro, or Bydureon BCise) within the past 90 days and prescriber confirms treatment or states patient is at risk if preferred agent is discontinued. Starting on samples is not approvable.
Not covered when
- Combination with DPP-4 inhibitors not permitted
- Combination with another GLP-1 receptor agonist not permitted
- FDA labeled contraindications apply
- Starting on samples is not approvable for continuation pathway
- Weight loss use is a benefit exclusion
- Fill limit: one GLP-1 agent and one strength per 28 days
- 2.5 mg strength must NOT be used for maintenance therapy (initiation/induction only)
Policy note: Mounjaro is listed as a preferred agent. Non-preferred agents (Byetta, Exenatide, Victoza) require two of the following prior preferred agent trials/failures: semaglutide (Ozempic or Rybelsus), dulaglutide (Trulicity), or tirzepatide (Mounjaro). Mounjaro is approved for T2DM in adults and pediatric patients 10 years and older per FDA labeling. Step therapy requirement may not apply if the requested medication was previously approved by another health plan and documentation of a paid claim within the past 90 days is submitted. Quantity limit override available for dose exceeding program QL with clinical justification including diagnosis of T2DM, dose does not exceed FDA maximum labeled dose, or support for higher dose. Fill limit override for switching GLP-1 agents/strengths is a one-time approval with a 6-month lockout for prior fill limit overrides.
Policy effective May 11, 2026 · verified June 5, 2026 · source: FL_GLP-1_PAQL_ProgSum.pdf