North Dakota Medicaid coverage for Mounjaro (Type 2

Medicaid

Covered with requirements

What you need to qualify

A1C no higher than 7%
Prior trial of another GLP-1 medication (Ozempic, Rybelsus, liraglutide, and Trulicity) for at least 90 days
Prescribed by or in consultation with a specialist
Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Pathway A: Diabetes with prior GLP-1 failure

All of:

Member has been unable to achieve goal A1C (≤7%) or TIR (>70%) despite a 90-day trial of triple combination therapy consisting of Ozempic (liraglutide, Rybelsus, and Trulicity must be trialed if Ozempic is not tolerated), along with metformin, SGLT-2 inhibitor or insulin, as evidenced by paid claims or pharmacy printouts
If triple therapy cannot be met with liraglutide/Ozempic/Rybelsus/Trulicity, clinical justification must be provided and triple therapy must be met with SGLT-2 inhibitor + DPP4 inhibitor + metformin

Plus any one of:

Requested medication prescribed by or in consult with an endocrinologist or diabetes specialist
Member has received diabetes education from a diabetic specialist, diabetic educator, or pharmacist (may be accomplished through the MTM program)

Pathway B: Member qualifies for tirzepatide based on Sleep Apnea criteria

All of:

Member is otherwise eligible for approval for tirzepatide based on the Sleep Apnea (OSA) criteria (see Zepbound OSA entry)
If member qualifies for tirzepatide, the most cost-effective tirzepatide product will be authorized

Documentation to bring

Evidence of inability to achieve goal A1C (≤7%) or TIR (>70%) despite 90-day trial of triple combination therapy (Ozempic/liraglutide/Rybelsus/Trulicity + metformin + SGLT-2 inhibitor or insulin), evidenced by paid claims or pharmacy printouts
Prescriber attestation of consultation with endocrinologist or diabetes specialist, OR documentation of diabetes education from diabetic specialist, educator, or pharmacist
If GI intolerance bypasses GLP-1 trial: chart documentation showing dietary changes, meal size reduction, prescription antiemetics, and dose adjustment were trialed for at least two months

Approval and renewal

Initial approval: 12 months
Renewal: every 12 months
To renew, the plan looks for Member must have experienced and maintained clinical benefit; must be at least 80% adherent.

Not covered when

DPP-4 inhibitors and GLP-1 agonists not payable together
Note: if member qualifies for tirzepatide, the most cost-effective tirzepatide product will be authorized (Mounjaro vs Zepbound)

Policy note: Mounjaro (tirzepatide) is a NON-PREFERRED GIP/GLP-1 agonist requiring PA. PA required. Step therapy requires trial of Ozempic-based triple therapy first (or liraglutide/Rybelsus/Trulicity if Ozempic not tolerated). Alternatively, member may qualify via the OSA tirzepatide pathway. The document states: 'If the member qualifies for tirzepatide, the most cost-effective tirzepatide product will be authorized' - meaning Mounjaro and Zepbound are interchangeable cost-effectively. GI intolerances (high dose IR metformin: must trial minimum 500mg ER; for GLP-1 GI effects: must document dietary changes, meal reduction, antiemetics, and dose adjustment for at least 2 months before bypassing trial requirement).

Policy effective April 1, 2026 · verified June 3, 2026 · source: PDL-2026.4.pdf

North Dakota Medicaid coverage for Mounjaro (Type 2 Diabetes)