Medicaid
Covered with requirementsWhat you need to qualify
- Prior trial of another GLP-1 medication (preferred GLP-1 receptor agonists approved for the beneficiary's diabetes diagnosis)
Qualification pathways
You can qualify through any one of these.
Non-preferred GLP-1 for diabetes — Mounjaro initial and renewal
All of:
- Diagnosis of diabetes
- The prescribed GLP-1 receptor agonist (Mounjaro/tirzepatide) is FDA-approved for the treatment of diabetes
Plus any one of:
- History of therapeutic failure of the maximum FDA-approved dose of preferred GLP-1 receptor agonist(s) approved/medically accepted for the beneficiary's diagnosis
- Contraindication to the maximum FDA-approved dose of preferred GLP-1 receptor agonist(s)
- Intolerance to the maximum FDA-approved dose of preferred GLP-1 receptor agonist(s) (with chart documentation of troubleshooting over >= 1 month if switching due to intolerance)
Documentation to bring
- Documentation of diabetes diagnosis
- Documentation of therapeutic failure of preferred GLP-1(s) at maximum FDA-approved dose, OR contraindication or intolerance (with troubleshooting documentation over >= 1 month if intolerance-based: dietary changes, prescription antiemetics, dose adjustment)
- Documentation that Mounjaro (tirzepatide) is FDA-approved for the treatment of diabetes
- Documentation of age-appropriateness per FDA labeling, compendia, or peer-reviewed literature
- Documentation of no contraindication to Mounjaro
- If therapeutic duplication: documentation of intent to transition or medical reason for concomitant use
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- To renew, the plan looks for Renewal requires: (1) diagnosis of diabetes; (2) therapeutic failure of/contraindication to/intolerance to maximum FDA-approved dose of preferred GLP-1(s) for the beneficiary's diagnosis; (3) Mounjaro is FDA-approved for diabetes. No A1C or weight thresholds re-checked at renewal.
Not covered when
- Overweight/obesity treatment indication excluded
- Saxenda (liraglutide) not covered for any indication
Policy note: Mounjaro is non-preferred for diabetes on the PA MA PDL. Requires therapeutic failure of, contraindication to, or intolerance to the maximum FDA-approved dose of preferred GLP-1(s) for the beneficiary's diabetes diagnosis. For intolerance-based switching (e.g., from semaglutide to tirzepatide), must document that troubleshooting was tried over at least 1 month: dietary changes (apples, crackers, mint/ginger drinks 30 minutes after dosing), prescription antiemetics, and dose adjustment if lower doses were tolerated. Approval for up to 12 months. Prescriptions limited to 1-month supply per fill.
Policy effective January 1, 2026 · verified June 4, 2026 · source: mab2025112403.pdf