Idaho Medicaid coverage for Mounjaro (Type 2 Diabetes)

What you need to qualify

• Diagnosis documented with a code (E11)

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• ICD-10 diagnosis code for type 2 diabetes mellitus in member's record or submitted with pharmacy claim

Policy note: Mounjaro (tirzepatide) is listed as a Non-Preferred Agent under the GLP-1 Receptor Agonists class. The document states criteria apply to preferred agents; the only criterion listed is an ICD-10 type 2 diabetes diagnosis. Non-preferred agents typically require PA on a Medicaid PDL; the document does not specify additional non-preferred criteria beyond the class-level T2DM diagnosis requirement. Rybelsus (semaglutide oral) is also listed as a Non-Preferred Agent and shares the same class criteria. Trulicity, Victoza, Bydureon BCISE, Byetta, and liraglutide also appear but are out of scope.

Policy effective January 1, 2026 · verified June 4, 2026 · source: policy-396.html