Applies to Medicaid plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
Preferred agent: Type 2 Diabetes (GLP-1/GIP RA class — tirzepatide)
All of:
- Request adheres to all FDA approved labeling for requested drug and indication, including age, dosing, contraindications, warnings and precautions, drug interactions, and use in specific populations
- Diagnosis of Type 2 Diabetes Mellitus
- Current A1C value provided
- Combination use with a DPP-4 inhibitor-containing agent is not requested
Non-preferred agent: Type 2 Diabetes (GLP-1/GIP RA class — tirzepatide) — if Mounjaro is non-preferred
All of:
- Request adheres to all FDA approved labeling for requested drug and indication, including age, dosing, contraindications, warnings and precautions, drug interactions, and use in specific populations
- Diagnosis of Type 2 Diabetes Mellitus
- Current A1C value provided
- Combination use with a DPP-4 inhibitor-containing agent is not requested
- Documentation of previous trials and therapy failures with a preferred drug in the same class
- Documentation of previous trials and therapy failures with at least 3 preferred agents from 3 different drug classes at maximally tolerated doses
Documentation to bring
- Current A1C lab result
- Documentation of FDA-approved indication and adherence to labeling (age, dosing, contraindications, warnings, drug interactions)
- If non-preferred: documentation of previous trials and therapy failures with preferred drug in the same class, including dates, dose, and nature of failure
- If non-preferred: documentation of previous trials and therapy failures with at least 3 preferred agents from 3 different drug classes at maximally tolerated doses, including dates, dose, and nature of failure
Not covered when
- Combination with DPP-4 inhibitor-containing agent will not be considered
- Pharmaceutical samples will not be considered when evaluating prior prescription history
- Duplicate use of drugs from the same therapeutic category will not be considered
Policy note: Mounjaro (tirzepatide) is included as an incretin mimetic/GLP-1 class agent covered for Type 2 Diabetes Mellitus under the Anti-Diabetics, Non-Insulin Agents section per rule 27a class expansion. The policy explicitly states that weight loss is not a covered diagnosis; only the diabetes indication is covered. If Mounjaro is a preferred agent, only the general criteria apply. If non-preferred, step therapy with 3 preferred agents from 3 different classes is also required. Required trials must be at appropriate dose and duration and documented with dates, dose, and nature of failure.
Policy effective June 1, 2026 · verified June 4, 2026 · source: Policy 387