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Kaiser Permanente Mid-Atlantic

Does Kaiser Permanente Mid-Atlantic cover Mounjaro?

Yes. Kaiser Permanente Mid-Atlantic covers Mounjaro for type 2 diabetes with prior authorization. Other policy requirements and your plan's benefits also apply.

Policy document

  • Hmo Exchange Prior Authorization Criteria En

    Kaiser Permanente Mid-Atlantic · PA policy · Employer, ACA Marketplace, and Federal Employee Program

    Effective June 2, 2026. Verified June 5, 2026.

    View PDF Download Original insurer source
  • Employer, ACA Marketplace, and Federal Employee Program: Covered with requirements. See the qualification pathways below.

Earliest policy review June 5, 2026. How we verify · Check your exact plan

Full requirements: Mounjaro for Type 2 Diabetes (3 plan types)

Applies to Employer, ACA Marketplace, and Federal Employee Program plans.

Covered with requirements

Qualification pathways

You can qualify through any one of these.

Initial approval for type 2 diabetes (non-preferred GLP-1/GIP: Mounjaro)

All of:

  • Diagnosis of type 2 diabetes mellitus
  • Most recent HbA1c obtained within 3 months of PA request
  • Patient is NOT on another GLP-1 agonist or any DPP-4 inhibitor
  • Failed adequate trial (adherence/MRAR ≥80% for at least 3 months) of metformin at maximum tolerated dose unless intolerance or contraindication
  • Failed adequate trial (adherence/MRAR ≥80% for at least 3 months) of an SGLT2 inhibitor (generic dapagliflozin preferred) at maximum tolerated dose unless intolerance or contraindication
  • Failed adequate trial (adherence/MRAR ≥80% for at least 3 months) of liraglutide (AG of Victoza) at maximum tolerated dose, unless intolerance or contraindication
  • Documented trial, intolerance, or contraindication to Ozempic

Plus any one of:

  • HbA1c is within 2% ABOVE goal (per ADA guidelines)
  • HbA1c is ≥2% ABOVE goal AND patient is optimized on concomitant insulin therapy (insulin glargine-yfgn preferred)

Documentation to bring

  • Diagnosis of type 2 diabetes mellitus
  • Most recent HbA1c lab result obtained within 3 months of PA request
  • Documentation of adequate trial (≥3 months, adherence/MRAR ≥80%) of metformin at maximum tolerated dose, OR documentation of intolerance or contraindication
  • Documentation of adequate trial (≥3 months, adherence/MRAR ≥80%) of an SGLT2 inhibitor (generic dapagliflozin preferred) at maximum tolerated dose, OR documentation of intolerance or contraindication
  • Documentation of adequate trial (≥3 months, adherence/MRAR ≥80%) of liraglutide (AG of Victoza) at maximum tolerated dose, OR documentation of intolerance or contraindication
  • Documentation of trial, intolerance, or contraindication to Ozempic
  • Documentation that patient is not currently on another GLP-1 agonist or DPP-4 inhibitor
  • If HbA1c ≥2% above goal with concomitant insulin: documentation that insulin regimen has been titrated to max tolerated dose or documentation of intolerance to insulin

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 6 months
  • Renewal: Improvement in A1C.
  • Renewal: If no diagnosis of ASCVD or indicators of high ASCVD risk, patient must meet ONE of: achieved goal A1C, documented A1C lowering of 1% from initial baseline prior to starting GLP-1, OR documented A1C lowering of 0.5% from time of last review. Also requires continued failure/intolerance/contraindication to liraglutide (AG of Victoza) and good adherence/MRAR ≥80% to diabetic regimen.

Not covered when

  • Patient currently on another GLP-1 agonist
  • Patient currently on a DPP-4 inhibitor
  • Type 1 diabetes

Policy note: Mounjaro (tirzepatide, a GIP/GLP-1 RA) is a non-preferred agent covered under the GLP-1 agonist class criteria. In addition to the base class step therapy (metformin, SGLT2 inhibitor, liraglutide), it requires documented trial, intolerance, or contraindication to Ozempic. For continuation: new members initiated outside KPMAS must confirm all initial review criteria. For existing members, continued failure/intolerance/contraindication to liraglutide must be documented, along with good adherence to the diabetic regimen. If ASCVD or high ASCVD risk is present, A1C requirements for continuation do not apply. The document references non-DM indications for Mounjaro/Zepbound as being covered under separate Zepbound criteria (not established in this document).

Policy effective June 2, 2026 · verified June 5, 2026 · source: Hmo Exchange Prior Authorization Criteria En · View policy document (PDF)

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Questions people ask
Does Kaiser Permanente Mid-Atlantic cover Mounjaro?
Yes. Kaiser Permanente Mid-Atlantic covers Mounjaro for type 2 diabetes with prior authorization. Other policy requirements and your plan's benefits also apply.
How long does a Mounjaro approval last with Kaiser Permanente Mid-Atlantic?
Type 2 Diabetes — Applies to Employer, ACA Marketplace, and Federal Employee Program plans. Initial approval: 6 months. Renewal: every 6 months.
What does Kaiser Permanente Mid-Atlantic require to renew Mounjaro?
Type 2 Diabetes — Applies to Employer, ACA Marketplace, and Federal Employee Program plans. Improvement in A1C. If no diagnosis of ASCVD or indicators of high ASCVD risk, patient must meet ONE of: achieved goal A1C, documented A1C lowering of 1% from initial baseline prior to starting GLP-1, OR documented A1C lowering of 0.5% from time of last review. Also requires continued failure/intolerance/contraindication to liraglutide (AG of Victoza) and good adherence/MRAR ≥80% to diabetic regimen.
How current is this information?
The oldest review date among the policies on this page is June 5, 2026. Each policy's effective and verification dates appear with its requirements. Confirm current benefits with your plan.

Also under Kaiser Permanente Mid-Atlantic: Ozempic, Wegovy, Zepbound

Mounjaro under other plans: Elevance Health, Alabama Medicaid, Arkansas Medicaid, California Medicaid, Colorado Medicaid, Connecticut Medicaid, Delaware Medicaid, Florida Medicaid

All insurance plans · All medications

Summary of Kaiser Permanente Mid-Atlantic's written policy, not a guarantee of coverage. Plans vary by employer and benefit design.