Medicaid
Covered with requirementsWhat you need to qualify
- A1C of 6.5% or higher
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
Initial Approval - Preferred GLP-1 Agent
All of:
- Recipient meets minimum age requirement per POS Edits
- Recipient has a diagnosis of type 2 diabetes mellitus
- A1C >= 6.5% obtained within the previous 6 months
Initial Approval - Non-Preferred GLP-1 Agent (if Mounjaro is non-preferred)
All of:
- Recipient meets minimum age requirement per POS Edits
- Recipient has a diagnosis of type 2 diabetes mellitus
- A1C >= 6.5% obtained within the previous 6 months
Plus any one of:
- Treatment failure with at least one preferred GLP-1 product
- Intolerable side effect to at least one preferred GLP-1 product
- Documented contraindication(s) to all preferred GLP-1 products appropriate for the condition
- No preferred product appropriate to use for the condition being treated
Documentation to bring
- Diagnosis of type 2 diabetes mellitus
- A1C lab result >= 6.5% obtained within the previous 6 months
- Minimum age verification per POS Edits
- If non-preferred: documentation of failure, intolerance, contraindication, or no preferred GLP-1 agent appropriate
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- To renew, the plan looks for Prescriber attests that recipient is established on the medication with evidence of a positive response to therapy.
Not covered when
- Type 1 diabetes
Policy note: Mounjaro is listed in the references section with its package insert, indicating it is covered as a GLP-1 agonist under this diabetes policy. The lower A1C pathway (A1C < 6.5% with CVD history) is explicitly limited to Trulicity, Victoza, and Ozempic — Mounjaro is NOT listed in that alternative pathway. Preferred vs. non-preferred status not specified in this document; see the Single PDL.
Policy effective November 15, 2024 · verified June 2, 2026 · source: MMA_and_POS_GLP_and_A1C_NOV_2024_10-11-24_Criteria.pdf