Applies to Medicaid plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
T2DM glycemic control
All of:
- Diagnosis of type 2 diabetes mellitus (T2DM)
- Prescribed as adjunct to diet and exercise to improve glycemic control
- Documentation of A1C lab results within past 180 days
- No history of pancreatitis
- Not prescribed for weight loss in absence of T2DM indication
- Prescribed at FDA-approved dose for T2DM indication
- Recipient is appropriate age per FDA label
Documentation to bring
- Documentation of T2DM diagnosis
- A1C lab result within past 180 days
- Confirmation of no history of pancreatitis
- Confirmation that medication is not being prescribed for weight loss in the absence of T2DM
- Prescription at FDA-approved dose for T2DM indication
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- Renewal: Documentation of positive response from therapy; recipient continues to meet all initial criteria.
Not covered when
- History of pancreatitis
- Prescribing for weight loss in absence of T2DM indication
- Type 1 diabetes
Policy note: Class-level criteria (Incretin Mimetics section KK) apply to Mounjaro as a member of the incretin mimetics class. Weight loss without T2DM is explicitly excluded. Appropriate age per FDA label is required but no specific minimum/maximum age stated for the T2DM indication.
Policy effective April 6, 2026 · verified June 3, 2026 · source: Msm 1200 26 04 06 · View policy document (PDF)