Employer / Commercial Insurance
Covered (preferred drug)
What you need to qualify
- Age 18 and older
- A1C of 7% or higher
- A1C no higher than 9%
- Diagnosis documented with a code (E11.0, E11.1, E11.2, E11.3, E11.4, E11.5, E11.6, E11.7, E11.8, E11.9)
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
Initial approval for Type 2 Diabetes
All of:
- Diagnosis of Type 2 diabetes mellitus
- Patient is at least 18 years of age
- A1C >= 7% and <= 9%
- Trial and failure of, or intolerance to at least 2 oral antidiabetic agents used in combination OR insulin, at maximal daily doses for at least 3 continuous months, in conjunction with diet and exercise per ADA Standards of Care, with inadequate glycemic control — documented within the last 6 months
Documentation to bring
- Documentation of Type 2 diabetes mellitus diagnosis
- ICD-10 diagnosis code for type 2 diabetes (E11.0–E11.9) — required on file for Traditional formulary PA
- A1C lab result showing value >= 7% and <= 9% (within last 6 months)
- Documentation of trial and failure of at least 2 oral antidiabetic agents used in combination OR insulin at maximal daily doses for at least 3 continuous months, with inadequate glycemic control, within the last 6 months
- Documentation that treatment was in conjunction with diet and exercise per ADA Standards of Care
Not covered when
- Medications in this category are only covered for type 2 diabetes mellitus
- Type 1 diabetes
Policy note: Mounjaro is listed as a Preferred Agent alongside Trulicity (dulaglutide) under the GLP-1 Receptor Agonists class. The policy explicitly states these medications are only covered for type 2 diabetes mellitus under the Priority Health Optimized and Traditional Formularies. For the Traditional formulary, PA is triggered only if the T2DM ICD-10 code is not already on file; for the Optimized formulary, the full criteria above always apply. No continuation/renewal criteria, quantity limits, or approval duration is stated for GLP-1s in this document. The document does not address weight loss, CV risk reduction, OSA, MASH, or CKD indications for any GLP-1.
Policy effective December 1, 2024 · verified June 10, 2026 · source: 81DACE8F00FF442799502209CC51780F.pdf
Medicaid
Covered with requirements
What you need to qualify
- Prior trial of another GLP-1 medication (Byetta, Ozempic, Trulicity, and Victoza)
Qualification pathways
You can qualify through any one of these.
Non-preferred agent — base criteria plus clinical exception
All of:
- Diagnosis of type 2 diabetes
- Discontinuation of other GLP-1 agonists
- Discontinuation of DPP-4 inhibitors
Plus any one of:
- Allergy to preferred medications
- Contraindication or drug-to-drug interaction with preferred medications
- History of unacceptable side effects with preferred medications
- Trial and failure with one preferred medication within same subgroup (GLP-1 agonists)
Documentation to bring
- Documentation of type 2 diabetes diagnosis
- Confirmation of discontinuation of other GLP-1 agonists
- Confirmation of discontinuation of DPP-4 inhibitors
- Documentation of allergy, contraindication, drug-to-drug interaction, unacceptable side effects, or trial and failure with one preferred GLP-1 agonist
Approval and renewal
- Initial approval: 12 months
Policy note: Mounjaro is listed as a non-preferred agent. In addition to the base non-preferred criteria (T2DM diagnosis, discontinuation of other GLP-1 agonists and DPP-4 inhibitors), at least one clinical exception must be met: allergy, contraindication/drug interaction, unacceptable side effects, or trial and failure with a preferred GLP-1 agonist. Approval duration is up to 1 year. The preferred GLP-1 agonists in this subgroup are Byetta, Ozempic, Trulicity, and Victoza.
Policy effective May 1, 2025 · verified June 10, 2026 · source: medicaid-rx-pa-criteria.pdf
ACA Marketplace
Covered (preferred drug)
What you need to qualify
- Age 18 and older
- A1C of 7% or higher
- A1C no higher than 9%
- Diagnosis documented with a code (E11.0, E11.1, E11.2, E11.3, E11.4, E11.5, E11.6, E11.7, E11.8, E11.9)
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
Initial approval for Type 2 Diabetes
All of:
- Diagnosis of Type 2 diabetes mellitus
- Patient is at least 18 years of age
- A1C >= 7% and <= 9%
- Trial and failure of, or intolerance to at least 2 oral antidiabetic agents used in combination OR insulin, at maximal daily doses for at least 3 continuous months, in conjunction with diet and exercise per ADA Standards of Care, with inadequate glycemic control — documented within the last 6 months
Documentation to bring
- Documentation of Type 2 diabetes mellitus diagnosis
- ICD-10 diagnosis code for type 2 diabetes (E11.0–E11.9) — required on file for Traditional formulary PA
- A1C lab result showing value >= 7% and <= 9% (within last 6 months)
- Documentation of trial and failure of at least 2 oral antidiabetic agents used in combination OR insulin at maximal daily doses for at least 3 continuous months, with inadequate glycemic control, within the last 6 months
- Documentation that treatment was in conjunction with diet and exercise per ADA Standards of Care
Not covered when
- Medications in this category are only covered for type 2 diabetes mellitus
- Type 1 diabetes
Policy note: Mounjaro is listed as a Preferred Agent alongside Trulicity (dulaglutide) under the GLP-1 Receptor Agonists class. The policy explicitly states these medications are only covered for type 2 diabetes mellitus under the Priority Health Optimized and Traditional Formularies. For the Traditional formulary, PA is triggered only if the T2DM ICD-10 code is not already on file; for the Optimized formulary, the full criteria above always apply. No continuation/renewal criteria, quantity limits, or approval duration is stated for GLP-1s in this document. The document does not address weight loss, CV risk reduction, OSA, MASH, or CKD indications for any GLP-1.
Policy effective December 1, 2024 · verified June 10, 2026 · source: 81DACE8F00FF442799502209CC51780F.pdf
