Kentucky Medicaid coverage for Mounjaro (Type 2 Diabetes)

What you need to qualify

• A1C of 6.5% or higher
• Diagnosis documented with a code (E11)
• Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• ICD-10 diagnosis of T2DM in chart notes within the past 12 months
• A1C lab value >= 6.5% (current within past 6 months; OR historical >= 6.5% PLUS current A1C within past 6 months)
• Attestation of no personal or family history of MTC or MEN 2
• Attestation that drug will not be combined with another GLP-1 or DPP-4 inhibitor (unless changing therapy)

Approval and renewal

• Initial approval: 6 months
• Renewal: every 6 months
• To renew, the plan looks for improvement in A1C and At renewal: ICD-10 diagnosis of T2DM (chart notes within past 12 months); A1C value within past 6 months; provider attestation of positive response to therapy (safety and efficacy); no personal/family history of MTC or MEN 2; not used in combination with another GLP-1 or DPP-4 (unless changing therapy); dose does not exceed maximum FDA-approved dose for diabetes.

Not covered when

• Drugs used for anorexia, weight loss, or weight gain are excluded from coverage under this benefit (per policy footnote: '*Drugs used for anorexia, weight loss, or weight gain are excluded from coverage.')

Policy note: Mounjaro is a Preferred agent (Preferred with PA). Non-preferred GLP-1s require >= 3-month trial and failure, allergy, contraindication, or intolerance of 2 preferred agents. GLP-1 medications are limited to two brand switches per year. The footnote '*Drugs used for anorexia, weight loss, or weight gain are excluded from coverage' appears in the GLP-1 section and applies to use of these agents for weight loss/anorexia purposes; coverage is limited to the T2DM indication.

Policy effective July 1, 2026 · verified July 7, 2026 · source: kentucky-medicaid-pa-criteria.pdf