South Carolina Medicaid coverage for Mounjaro (Type 2 Diabetes)

What you need to qualify

• Age 18 and older
• Trial of metformin for at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication"])
• Prior trial of another GLP-1 medication (Ozempic, Trulicity, and Victoza)
• Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Documented diagnosis of T2DM
• Evidence of metformin trial and failure, intolerance, or contraindication (90-day lookback for paid claims in history)
• Baseline A1C lab result within the previous 3 months
• Confirmation that requested dose does not exceed maximum FDA-approved dose for diabetes
• Documentation of trial and failure of a preferred product (Ozempic, Trulicity, or Victoza), OR clinical rationale why preferred products cannot be used

Approval and renewal

• Initial approval: 6 months
• Renewal: every 12 months
• To renew, the plan looks for improvement in A1C and Reduction in A1C from baseline, OR A1C goal achieved, OR improvement in fasting blood glucose levels. Supporting documentation within the previous 3 months required. Patient must not have experienced any treatment-restricting adverse events.

Policy note: Mounjaro is listed under 'Other Products' and is a non-preferred agent. It requires the same base criteria as preferred products (Ozempic, Trulicity, Victoza) PLUS a trial or failure of a preferred product, or rationale for why preferred products cannot be used. The document does not explicitly state that prior_glp1_trial duration must meet a specific threshold — only that a trial and failure occurred. The document does not address Mounjaro for weight_loss indication at all; no entry emitted for that.

Policy effective May 1, 2026 · verified June 4, 2026 · source: SCRx_PAcriteria_GLP1s.pdf