Illinois Medicaid coverage for Mounjaro (Type 2 Diabetes)

What you need to qualify

• A1C no higher than 10%
• Trial of metformin for at least 90 days, or a documented reason it can't be used (["intolerance", "hypersensitivity", "contraindication"])
• Prior trial of another GLP-1 medication (Trulicity, Victoza, and liraglutide) for at least 90 days
• Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Baseline A1C lab result within 3-6 months
• Documentation that current HgbA1C is above goal
• Documentation that requested medication is age-appropriate (per Table 1)
• Documentation of metformin trial at optimized dose for at least 3 months with inadequate response, OR documented intolerance/hypersensitivity/contraindication to metformin
• Documentation of ineffective treatment response to preferred injectable GLP1-RAs (Trulicity AND [Victoza OR liraglutide]) at optimized dose for at least 3 months, OR documented intolerance/hypersensitivity/contraindication to preferred injectable GLP1-RAs (for non-preferred agent)
• For ASCVD pathway: Baseline lipid labs (TC, LDL); documentation of concurrent ASCVD or high ASCVD risk; documentation that Mounjaro has demonstrated CV benefits
• For CKD pathway: Baseline GFR/CrCL/albuminuria labs; documentation of CKD; documentation that Mounjaro has demonstrated CKD benefits; documentation of SGLT2i trial/failure or contraindication
• For HFpEF pathway: LVEF >= 50% documentation; BMI/weight/height; documentation of HFpEF and obesity; documentation of SGLT2i trial/failure x2 or contraindication
• For MASH pathway: LFTs, FIB-4, BMI; biopsy-proven MASH; documentation of pioglitazone trial/failure or contraindication; documentation of liraglutide trial/failure or contraindication

Approval and renewal

• Initial approval: 6 months
• Renewal: every 12 months
• To renew, the plan looks for History of compliance and documented positive response to medication.

Not covered when

• Concurrent use of DPP4-I, other GLP1-RA (oral or injectable), or GLP1/GIP
• History of pancreatitis
• Personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia type 2A/2B
• HgbA1C > 10% in individuals with T2DM
• Liver cirrhosis (for MASH diagnosis pathway)
• Medication requested for obesity alone or in combination with another condition secondary to obesity (IL Medicaid policy)
• Pregnancy
• Type 1 diabetes

Policy note: Non-preferred agent on Illinois Medicaid PDL. Preferred agents are Trulicity (dulaglutide), Victoza (liraglutide), and liraglutide (generic) — all Step 4. Mounjaro requires step therapy through preferred injectable GLP1-RAs. Step therapy requires trial of BOTH Trulicity AND (Victoza OR liraglutide) unless intolerance/contraindication documented. Obesity alone or secondary to another condition is explicitly excluded per IL Medicaid policy. Initial approval is 30-day supplies for 6 months; renewal is 30-day supplies for 12 months. Table 1 referenced for age-appropriateness and cardiovascular/CKD benefit verification but not reproduced in this document. Note: Mounjaro's cardiovascular and CKD benefits per Table 1 are referenced but not confirmed in document text; reviewer should verify Table 1 includes Mounjaro for these pathways.

Policy effective April 29, 2025 · verified June 4, 2026 · source: policy-359.html