Indiana Medicaid coverage for Mounjaro (Type 2

Medicaid

Covered with requirements

What you need to qualify

Age 10 and older
Prior trial of 2 other GLP-1 medications (Ozempic, Trulicity, and Victoza) for at least 90 days
Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Non-Preferred: Step through TWO preferred GLP-1 RAs with inadequate response

All of:

Member is 10 years of age or older
Diagnosis of type 2 diabetes mellitus confirmed by chart documentation or claims history
Baseline HbA1c submitted, obtained within past 90 days (lab documentation required)
Member is not on concomitant DPP-4 inhibitor OR is transitioning (45-day transition permitted)
Member will not use concurrently with another GLP-1 RA or combination product
Trial and failure of TWO different preferred GLP-1 RA agents; at least one must be Ozempic (semaglutide) or Trulicity (dulaglutide) — as applicable based on FDA-approved age limit
Each preferred agent trial at optimized dose (Ozempic 2mg/week, Trulicity 4.5mg/week, Victoza 1.8mg/day) for at least 90 days, with HbA1c lab evidence of insufficient response for each

Plus any one of:

History of at least 90 days of preferred GLP-1 RA therapy at optimized dose for EACH of two agents, with submitted HbA1c lab reports showing insufficient response to each
Medical justification for use of Mounjaro over Ozempic, Trulicity, AND Victoza (GI adverse effects are not considered intolerance; must be supported by chart notes)

Documentation to bring

Chart documentation or claims history confirming T2DM diagnosis
Baseline HbA1c lab result obtained within past 90 days
Claims history, chart documentation, or provider attestation of trial and failure of TWO preferred GLP-1 RA agents (at least one must be Ozempic or Trulicity), each at optimized dose for >=90 days, including dates of trial
Submitted HbA1c lab reports with collection dates demonstrating insufficient response to each preferred agent trialed, OR medical justification for use over all three preferred agents with chart note support
Documentation confirming no concomitant DPP-4 inhibitor use (or 45-day transition plan)

Quantity limits

all strengths (members >=18 years) — max 15 mg/week
all strengths (members <18 years) — max 10 mg/week

Approval and renewal

Initial approval: 6 months
Renewal: every 12 months
To renew, the plan looks for improvement in A1C, At reauthorization: HbA1c reduction from baseline OR trend toward stabilization over past year. If neither, prescriber must submit medical justification with chart note support. HbA1c within past 90 days (<1 year on therapy) or 180 days (>=1 year on therapy). Must have history of requested agent at least 84 days within past 112 days. Continued step-therapy requirement (TWO preferred GLP-1 RA failures) must be re-verified at reauthorization, and at least 12 weeks on therapy before the first renewal.

Not covered when

No concurrent use with another GLP-1 RA or combination product
No concurrent DPP-4 inhibitor (45-day transition permitted)
Adults: dose must not exceed 15 mg/week; pediatric (<18 years): dose must not exceed 10 mg/week

Policy note: Non-preferred agent. Requires failure of TWO preferred GLP-1 RAs; at least one must be Ozempic or Trulicity (age-appropriate). GI adverse effects explicitly stated to not qualify as intolerance. Dose limits differ by age: >=18 years max 15 mg/week; <18 years max 10 mg/week. Minimum age is 10 years. Step-therapy requirement is re-evaluated at reauthorization.

Policy effective July 1, 2026 · verified June 4, 2026 · source: 20260701_Public-Facing_GLP-1%20RA-GIP-Combinations_PA_Final.pdf

Indiana Medicaid coverage for Mounjaro (Type 2 Diabetes)