Kaiser Permanente Mid-Atlantic

Does Kaiser Permanente Mid-Atlantic cover Mounjaro?

Quick answer · Type 2 Diabetes

Kaiser Permanente Mid-Atlantic covers Mounjaro for type 2 diabetes with prior authorization on Employer / Commercial Insurance, ACA Marketplace, and Federal Employee Program.

  • Employer / Commercial Insurance: Covered with requirements. Trial of metformin for at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication"])
  • ACA Marketplace: Covered with requirements. Trial of metformin for at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication"])
  • Federal Employee Program: Covered with requirements. Trial of metformin for at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication"])

Last verified June 5, 2026. Policy effective June 2, 2026. Source: hmo-exchange-prior-authorization-criteria-en.pdf. How we verify this data →

Check your card for your exact plan →

Mounjaro for Type 2 Diabetes

What Kaiser Permanente Mid-Atlantic requires, by plan type. Open this indication on its own page →

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

  • Trial of metformin for at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication"])
  • Prior trial of another GLP-1 medication (Ozempic)
  • Lab results confirming eligibility

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
  • To renew, the plan looks for improvement in A1C and 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.pdf

ACA Marketplace

Covered with requirements

What you need to qualify

  • Trial of metformin for at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication"])
  • Prior trial of another GLP-1 medication (Ozempic)
  • Lab results confirming eligibility

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
  • To renew, the plan looks for improvement in A1C and 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.pdf

Federal Employee Program

Covered with requirements

What you need to qualify

  • Trial of metformin for at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication"])
  • Prior trial of another GLP-1 medication (Ozempic)
  • Lab results confirming eligibility

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
  • To renew, the plan looks for improvement in A1C and 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.pdf

Why Mounjaro requests get denied by Kaiser Permanente Mid-Atlantic

Based on what this policy asks for. Fix these before the first submission.

  1. Wrong brand for the diagnosis. Mounjaro and Zepbound are the same molecule with different approved uses; a request for Mounjaro under a diagnosis that matches Zepbound is routinely denied.
  2. No documented metformin trial (dose, dates, and outcome) or a stated reason it can't be used.
  3. Required prior medication trials not documented.

Frequently asked questions

Does Kaiser Permanente Mid-Atlantic cover Mounjaro?
Kaiser Permanente Mid-Atlantic covers Mounjaro for type 2 diabetes with prior authorization on Employer / Commercial Insurance, ACA Marketplace, and Federal Employee Program.
Do you have to try metformin before Mounjaro?
Yes for type 2 diabetes: Kaiser Permanente Mid-Atlantic requires a documented trial of metformin of at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication"]).
How long does a Mounjaro approval last with Kaiser Permanente Mid-Atlantic?
Initial approvals last 6 months, and renewals are granted in 6-month periods.
What does Kaiser Permanente Mid-Atlantic require to renew Mounjaro?
Improvement in A1C and 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?
This page reflects Kaiser Permanente Mid-Atlantic's written policy as of June 2, 2026, last verified against the source document on June 5, 2026.

Other medications under Kaiser Permanente Mid-Atlantic

Mounjaro coverage under other plans

All insurance plans · All medications

This page summarizes Kaiser Permanente Mid-Atlantic's written prior-authorization policy. It is not a guarantee of coverage; plans vary by employer and benefit design. Verify with your plan before relying on it.