Employer / Commercial Insurance
Covered (preferred drug)What you need to qualify
- Age 10 and older
- Trial of metformin for at least 90 days, or a documented reason it can't be used (["contraindication"])
Qualification pathways
You can qualify through any one of these.
Initial approval for Type 2 Diabetes (First-Line, adults and pediatric)
All of:
- Individual is aged 10 years or older
- Diagnosed with type 2 diabetes
- Has had an adequate trial of or a contraindication to metformin
- Drug will not be used in combination with another GLP-1 or GIP/GLP-1 receptor agonist
- Does not exceed FDA labeled maximum daily dose
Documentation to bring
- Office visit notes containing the diagnosis of type 2 diabetes
- Relevant history and physical evaluation
- Medication history documenting adequate trial of or contraindication to metformin
- Documentation that drug will not be used in combination with another GLP-1 or GIP/GLP-1 receptor agonist
Quantity limits
- 2.5 mg/0.5 mL — 4 pens (2 mL)
- 5 mg/0.5 mL — 4 pens (2 mL)
- 7.5 mg/0.5 mL — 4 pens (2 mL)
- 10 mg/0.5 mL — 4 pens (2 mL)
- 12.5 mg/0.5 mL — 4 pens (2 mL)
- 15 mg/0.5 mL — 4 pens (2 mL)
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- To renew, the plan looks for Re-authorization approved up to 12 months as long as drug-specific coverage criteria are met and chart notes demonstrate the individual continues to show a positive clinical response to therapy.
Not covered when
- Use in combination with another GLP-1 or GIP/GLP-1 receptor agonist is excluded
- Exceeding FDA labeled maximum daily dose is excluded
Policy note: Mounjaro is listed as a first-line preferred GIP/GLP-1 receptor agonist for type 2 diabetes in adults and pediatric individuals aged 10 and older. The policy states that 'adequate trial of or a contraindication to metformin' is required but does not specify a duration for the metformin trial. Mounjaro is also listed as one of the qualifying step-therapy drugs that must be tried before Victoza (liraglutide) can be approved, but Mounjaro itself does not require prior GLP-1 trial. Diagnosis of type 2 diabetes must meet criteria defined in the Related Information section.
Policy effective May 1, 2026 · verified June 3, 2026 · source: 5.01.569.pdf