Applies to Medicaid and ACA Marketplace plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
Step therapy for formulary drugs
All of:
- Medication is being used for treatment of type 2 diabetes mellitus
Plus any one of:
- Documentation or prescriber attestation that metformin has been ineffective in the treatment of the member's disease or medical condition OR is likely to be ineffective
- Documentation or prescriber attestation that metformin has caused or is likely to cause a clinically significant adverse reaction or other harm
Type 2 Diabetes Mellitus — initial approval
All of:
- Documentation of diagnosis of type 2 diabetes mellitus
- Documentation of inadequate treatment response, contraindication, or serious side effects to 3 consecutive months of metformin at maximal daily doses
- Documentation by prescriber of baseline disease activity and individualized goals for therapy (e.g., A1C, weight management, glycemic targets)
- Prescriber attests no unaddressed FDA-labeled contraindications (hypersensitivity to product; history/family history of MTC; MEN2)
Plus any one of:
- FOR NON-FORMULARY/NON-PREFERRED SINGLE AGENTS: Documented inadequate response, serious side effects, or contraindication to ALL formulary/preferred agents within the same therapeutic class
- FOR COMBINATION PRODUCTS: Documented inadequate response, serious side effects, or contraindication to ALL formulary/preferred combination agents with matching therapeutic class OR to ALL matching class formulary single agents within the requested combination product
Documentation to bring
- Documentation of diagnosis of type 2 diabetes mellitus
- Documentation of inadequate treatment response, contraindication, or serious side effects to 3 consecutive months of metformin at maximal daily doses
- Prescriber documentation of baseline disease activity and individualized therapeutic goals (e.g., A1C, weight, glycemic targets)
- Prescriber attestation of no unaddressed FDA-labeled contraindications
- For non-preferred/non-formulary agents: Documentation of failure, intolerance, or contraindication to all formulary/preferred agents in the same class
- For CA/FL/KY/WA Marketplace: Approval letter or coverage documentation showing the step-therapy formulary drug was covered by the member's previous insurer
Quantity limits
- 2.5mg, 5mg, 7.5mg, 10mg, 12.5mg, 15mg — 4 pens per 28 days (maximum 15mg/week)
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- Renewal: Improvement in A1C.
- Renewal: Documentation of positive clinical response as demonstrated by improvement in hemoglobin A1C OR member has reached individualized goals. Also requires adherence ≥ 85% and no evidence of intolerable adverse effects.
Not covered when
- Hypersensitivity to requested product or any component of the formulation
- History of or family history of medullary thyroid carcinoma (MTC)
- Multiple endocrine neoplasia syndrome type 2 (MEN2)
- Pre-diabetes
- Any disorder of glucose not classified specifically as type 2 diabetes
- Weight loss, obesity (explicitly excluded per Social Security 1927(d)(2)(A))
- Type 1 diabetes
Exceptions
- Illinois_Marketplace: Off-formulary exception shall not be denied if: (1) formulary drug is contraindicated; (2) patient tried formulary drug under current or previous plan and prescriber submits evidence of failure or intolerance; or (3) patient is stable on a drug selected by their provider under current or previous plan. Approvals honored for 12 months or until plan renewal.
- CA_FL_KY_WA_Marketplace: Approval letter or other coverage documentation showing the formulary step-therapy drug was covered by previous insurer also meets the step therapy criteria.
Policy note: Mounjaro (tirzepatide) is classified as a GIP & GLP-1 Agonist. Age restriction is 10 years and older (pediatric approval included). Quantity limit is maximum 15mg/week, 4 pens per 28 days. Weight loss indication is explicitly excluded per Social Security 1927(d)(2)(A). Black box warning for thyroid C-cell tumors noted. Molina Reviewer Note states the T2DM indication includes medications with indication of T2DM AND cardiovascular disease or chronic kidney disease.
Policy effective May 30, 2026 · verified June 11, 2026 · source: 831 B5446 D9 D44 Edca352296 E84 F1 Dcd5 · View policy document (PDF)