Employer / Commercial Insurance
Covered (preferred drug)What you need to qualify
- Diagnosis documented with a code (E11)
Qualification pathways
You can qualify through any one of these.
Route 1: Type 2 Diabetes Diagnosis
All of:
- Diagnosis of type 2 diabetes (T2DM)
Route 2: Point-of-Sale Clinical Edit (ICD-10 or prior therapy claims)
Plus any one of:
- ICD-10 code for type 2 diabetes (E11*) within the past 2 years
- Adjudicated and paid claims for a contingent therapy (biguanides, insulin, amylin analogs, sulfonylureas, meglitinide analogues, alpha-glucosidase inhibitors, DPP-4 inhibitors, insulin sensitizing agents, SGLT2 inhibitors, or antidiabetic combinations) — 56-day supply in 120 days
- Auto-grandfather: prior paid claim for Mounjaro, Ozempic, Rybelsus, or Trulicity within 120 days
Documentation to bring
- Diagnosis of type 2 diabetes OR ICD-10 code E11* within past 2 years OR adjudicated claims for qualifying contingent antidiabetic therapy (56-day supply in 120 days)
- Chart notes or clinical documentation confirming medical necessity and clinical benefit (for continuation)
Quantity limits
- all available strengths — 4 pens per 28 days
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- To renew, the plan looks for Clinical documentation (such as chart notes) must confirm that current medical necessity criteria are met and that the medication is providing clinical benefit, such as disease stability or improvement.
Not covered when
- Diabetic ketoacidosis (DKA)
- Islet-cell transplantation
- Use in combination with Symlin (pramlintide) or another GLP-1 agonist-containing medication
- Weight loss in the absence of coverable medical conditions
- Type 1 diabetes
Policy note: Policy covers Mounjaro under the pharmacy benefit only (self-administered). Point-of-sale clinical edits in Appendix 1 provide an alternative pathway via ICD-10 code E11* (2-year lookback) or prior paid claims for contingent antidiabetic therapies (56-day supply in 120 days), or auto-grandfather based on prior paid claims for Mounjaro/Ozempic/Rybelsus/Trulicity within 120 days. Authorization reviewed at least annually.
Policy effective April 15, 2026 · verified June 3, 2026 · source: dru750reg.pdf