Medicaid
Covered with requirementsWhat you need to qualify
- Diagnosis documented with a code
- Trial of metformin for at least 90 days, or a documented reason it can't be used (["contraindication"])
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
T2DM with metformin failure or contraindication
All of:
- Diagnosis of Type 2 diabetes mellitus
- Prescriber will not switch to a preferred product OR preferred product has been considered
Plus any one of:
- Tried and failed to meet hemoglobin A1C goals with metformin
- Contraindication to metformin
Documentation to bring
- ICD-10 diagnosis code for Type 2 diabetes mellitus
- Documentation of metformin trial and failure to meet A1C goals, OR documentation of metformin contraindication
- Documentation that prescriber considered switching to a preferred product
Approval and renewal
- Initial approval: 12 months
Not covered when
- Type 1 diabetes
Policy note: Mounjaro is covered under the class-level GLP-1/GIP receptor agonist PA criteria. Same criteria as GLP-1 agonists for T2DM. The policy title explicitly includes GIP receptor agonists alongside GLP-1 receptor agonists. Non-preferred products require PA. For weight loss indication, the policy references a separate weight management PA criteria document. Metformin titration schedule is provided. The document does not specify a minimum metformin trial duration in days.
Policy effective March 1, 2026 · verified June 4, 2026 · source: Oregon%20Medicaid%20PA%20Criteria%20Guide%20-%20June%201%2C%202026.pdf