Washington Medicaid coverage for Mounjaro (Type 2

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

Washington Medicaid coverage for Mounjaro (Type 2 Diabetes)