New York Medicaid coverage for Mounjaro (Type 2 Diabetes)

No additional clinical requirements are listed beyond the diagnosis.

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Confirmation of FDA-approved or compendia-supported diagnosis that is a Medicaid covered indication
• If concurrent GLP-1 and DPP-IV use: PA required with documentation of clinical rationale

Policy note: Mounjaro is listed as a Non-Preferred drug on the NYRx PDL under GLP-1 Receptor Agonists – Type 2 Diabetes with Clinical Criteria (CC). The same class-level clinical criteria apply: (1) confirmed diagnosis of an FDA-approved or compendia-supported indication that is also a Medicaid covered indication; (2) PA required if the patient is using a GLP-1 and DPP-IV concurrently. As a Non-Preferred agent, PA is also implicitly required to justify non-preferred use over preferred alternatives (e.g., Ozempic, exenatide, Trulicity). The document does not provide additional quantitative non-preferred step-therapy criteria beyond the class CC. A standardized PA fax form is available at https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Fax_Standardized.pdf. The document lists this section as revised April 23, 2026; Mounjaro was noted as Non-Preferred as of 2/19/2026.

Policy effective April 23, 2026 · verified June 3, 2026 · source: nyrx_pdp_pdl.pdf