Medicaid
Covered (preferred drug)What you need to qualify
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
Initial approval for type 2 diabetes
All of:
- Appropriate diagnosis of type 2 diabetes
- Baseline A1C dated within 90 days prior to initiation
- Requested agent will not be used in combination with another GLP-1 receptor agonist
- If requested quantity exceeds quantity limits, clinical rationale provided
SmartPA for type 2 diabetes (no PA request needed)
All of:
- Claims within quantity limit
- Member has history of medical claims for type 2 diabetes mellitus OR history of medical claims for prediabetes with history of paid claims for at least 84 days of GLP-1/GIP/GLP-1 agonist therapy within the last 120-day period
Documentation to bring
- Appropriate diagnosis of type 2 diabetes
- Baseline A1C lab result dated within 90 days prior to initiation
- Attestation that requested agent will not be used in combination with another GLP-1 receptor agonist
- If quantity exceeds limits: clinical rationale why dose cannot be consolidated or for exceeding FDA-approved dosing
- For recertification: current A1C dated within last 90 days
- For recertification: evidence of A1C reduction, A1C ≤ 7%, or treatment plan for A1C escalation
Quantity limits
- all strengths — 1 carton of 4 prefilled pens per 28-day supply
Approval and renewal
- To renew, the plan looks for improvement in A1C and Current A1C within last 90 days required. Must show: reduction in A1C since initiation, OR A1C ≤ 7% (dated within last 90 days), OR treatment plan addressing escalation of therapy for A1C reduction.
Not covered when
- Combination use with another GLP-1 receptor agonist is prohibited unless transitioning (with discontinuation of prior GLP-1)
Policy note: Mounjaro is a Preferred Drug (PD) in the MassHealth formulary for type 2 diabetes (listed as GIP/GLP-1 Agonist). No step therapy through lower-potency GLP-1s is required for initial T2DM approval. Mounjaro 15 mg (maximum dose) is itself a step-therapy prerequisite for other agents (e.g., Bydureon Bcise, Rybelsus, Soliqua, Xultophy) requiring prior failure of 'high-potency GLP-1s'. Prediabetes indication also covered under same section with metformin step-therapy requirements. SmartPA pathway applies.
verified June 4, 2026 · source: policy-348.html