Applies to Medicaid plans.
Covered with requirementsQualification 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
- Renewal: 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 A1 C Nov 2024 10 11 24 Criteria · View policy document (PDF)