Do you have to try metformin before Mounjaro?

Yes for type 2 diabetes: Washington Medicaid requires a documented trial of metformin of at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication", "clinically_inappropriate"]).

How long does a Mounjaro approval last with Washington Medicaid?

Initial approvals last 12 months, and renewals are granted in 12-month periods.

What does Washington Medicaid require to renew Mounjaro?

Improvement in A1C and HbA1c ≤ 7 OR improved from baseline prior to GLP-1 treatment; diagnosis of T2DM confirmed; not used in combination with another GLP-1 agonist or DPP4 inhibitor. BMI and prior therapy step requirements are NOT re-verified at continuation.

How current is this information?

This page reflects Washington Medicaid's written policy as of June 1, 2026, last verified against the source document on June 4, 2026.

Does Washington Medicaid cover Mounjaro?

Mounjaro for Type 2 Diabetes

What Washington Medicaid requires, by plan type. Open this indication on its own page →

Medicaid

Covered with requirements

What you need to qualify

Age 10 and older
A1C of 6.5% or higher
Trial of metformin for at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication", "clinically_inappropriate"])
Prior trial of another GLP-1 medication (liraglutide) for at least 90 days
Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Non-preferred agent (Mounjaro) for T2DM — initial approval

All of:

Diagnosis of type 2 diabetes OR HbA1c ≥ 6.5 within the last 12 months
Patient is ≥ 10 years old
Drug will not be used in combination with another GLP-1 agonist or DPP4 inhibitor
History of failure (inability to achieve HbA1c < 7%) on metformin at maximum or highest tolerated dose for a minimum of 90 continuous days (unless not tolerated, contraindicated, or clinically inappropriate)
History of failure (inability to achieve HbA1c < 7%) on liraglutide at maximum or highest tolerated dose for a minimum of 90 continuous days (unless not tolerated, contraindicated, or clinically inappropriate)

Documentation to bring

Diagnosis of type 2 diabetes OR HbA1c lab result ≥ 6.5 within the last 12 months
Documentation of patient age (≥ 10 years)
Documentation confirming drug will not be combined with another GLP-1 agonist or DPP4 inhibitor
Documentation of metformin trial at maximum or highest tolerated dose for ≥ 90 continuous days with inadequate response (HbA1c not achieving <7%), OR documentation of intolerance/contraindication/clinical inappropriateness
Documentation of liraglutide trial at maximum or highest tolerated dose for ≥ 90 continuous days with inadequate response (HbA1c not achieving <7%), OR documentation of intolerance/contraindication/clinical inappropriateness

Quantity limits

2.5mg/0.5mL — 2 mL per 28 days
5mg/0.5mL — 2 mL per 28 days
7.5mg/0.5mL — 2 mL per 28 days
10mg/0.5mL — 2 mL per 28 days
12.5mg/0.5mL — 2 mL per 28 days
15mg/0.5mL — 2 mL per 28 days

Approval and renewal

Initial approval: 12 months
Renewal: every 12 months
To renew, the plan looks for improvement in A1C and HbA1c ≤ 7 OR improved from baseline prior to GLP-1 treatment; diagnosis of T2DM confirmed; not used in combination with another GLP-1 agonist or DPP4 inhibitor. BMI and prior therapy step requirements are NOT re-verified at continuation.

Not covered when

Concurrent use with another GLP-1 agonist
Concurrent use with a DPP4 inhibitor

Policy note: Mounjaro is a non-preferred agent. Minimum age is 10 years (pediatric approval per version 27.17.00-4 update). Adult max dose is 15 mg weekly; pediatric max dose is 10 mg weekly. Step-through requires BOTH metformin AND liraglutide (preferred agents). This standard T2DM entry applies when OSA is NOT present — the OSA-specific indication has separate criteria captured separately. Rybelsus (oral semaglutide) is listed in the medical necessity table but is in-scope only for the diabetes indication under Ozempic brand — Rybelsus criteria appear to mirror the same class criteria as it is listed alongside Ozempic (semaglutide) under the same drug entry in the policy table; however per rule 27 and the in-scope list, Rybelsus is not a separately tracked brand in scope.

Policy effective June 1, 2026 · verified June 4, 2026 · source: antidiabetics-GLP-1-agonists.pdf

Why Mounjaro requests get denied by Washington Medicaid

Based on what this policy asks for. Fix these before the first submission.

Wrong brand for the diagnosis. Mounjaro and Zepbound are the same molecule with different approved uses; a request for Mounjaro under a diagnosis that matches Zepbound is routinely denied.
No recent A1C result on file.
No documented metformin trial (dose, dates, and outcome) or a stated reason it can't be used.
Required prior medication trials not documented.

Frequently asked questions

Does Washington Medicaid cover Mounjaro?: Washington Medicaid covers Mounjaro for type 2 diabetes with prior authorization on Medicaid.
Do you have to try metformin before Mounjaro?: Yes for type 2 diabetes: Washington Medicaid requires a documented trial of metformin of at least 90 days, or a documented reason it can't be used (["intolerance", "contraindication", "clinically_inappropriate"]).
How long does a Mounjaro approval last with Washington Medicaid?: Initial approvals last 12 months, and renewals are granted in 12-month periods.
What does Washington Medicaid require to renew Mounjaro?: Improvement in A1C and HbA1c ≤ 7 OR improved from baseline prior to GLP-1 treatment; diagnosis of T2DM confirmed; not used in combination with another GLP-1 agonist or DPP4 inhibitor. BMI and prior therapy step requirements are NOT re-verified at continuation.
How current is this information?: This page reflects Washington Medicaid's written policy as of June 1, 2026, last verified against the source document on June 4, 2026.