Medicaid
Covered with requirementsNo additional clinical requirements are listed beyond the diagnosis.
Qualification pathways
You can qualify through any one of these.
Preferred Agent Criteria
All of:
- Diagnosis of type 2 diabetes
- Discontinuation of other GLP-1 agonists
- Discontinuation of DPP-4 inhibitors
Non-Preferred Agent Criteria
All of:
- Diagnosis of type 2 diabetes
- Discontinuation of other GLP-1 agonists
- Discontinuation of DPP-4 inhibitors
Plus any one of:
- Allergy to the preferred medications
- Contraindication or drug-to-drug interaction with the preferred medications
- History of unacceptable side effects
- Trial and failure with one preferred medication within same subgroup
Documentation to bring
- Documentation of type 2 diabetes diagnosis
- Documentation of discontinuation of other GLP-1 agonists
- Documentation of discontinuation of DPP-4 inhibitors
- If non-preferred: documentation of allergy, contraindication, drug interaction, unacceptable side effects, or trial and failure with a preferred agent in the same subgroup
Quantity limits
- all strengths — 12 pens per 84 days (84-day)
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
Policy note: Mounjaro is listed in the Michigan Medicaid PDL under 'Diabetes: Incretin Mimetics and Combinations'. Preferred vs. non-preferred status is determined by the Michigan Preferred Drug List (PDL), which is referenced but not fully reproduced in this document. The criteria apply to the PDL class broadly; whether Mounjaro is preferred or non-preferred is not explicitly stated in the excerpt.
Policy effective July 1, 2026 · verified June 4, 2026 · source: MIRx_clinical_criteria.pdf