Applies to Employer and ACA Marketplace plans.
Covered (preferred drug)Qualification pathways
You can qualify through any one of these.
Auto-adjudication via claims history
All of:
- ICD-10 diagnosis code for type 2 diabetes mellitus present in member's medical claims history
Prior authorization — confirmed T2DM diagnosis
Plus any one of:
- History of A1C ≥ 6.5%
- History of 2-hour plasma glucose ≥ 200 mg/dL during OGTT
- History of symptoms of hyperglycemia (polyuria, polydipsia, polyphagia) or hyperglycemic crisis AND random plasma glucose ≥ 200 mg/dL
- History of fasting plasma glucose (FPG) ≥ 126 mg/dL
Documentation to bring
- Chart notes or medical record documentation supporting a diagnosis of type 2 diabetes mellitus (A1C > 6.5%, 2-hour plasma glucose ≥ 200 mg/dL during OGTT, symptoms of hyperglycemia with random plasma glucose ≥ 200 mg/dL, or fasting plasma glucose ≥ 126 mg/dL)
Quantity limits
- all strengths — 4 pens/28 days
Approval and renewal
- Initial approval: 12 months
Not covered when
- Diabetic ketoacidosis
- Not a substitute for insulin
- Weight reduction/management use is a standard exclusion for most benefits
- Type 1 diabetes
Policy note: Mounjaro is listed as a preferred product. The policy uses a screen-out logic: if an ICD-10 code for T2DM is present in claims history, the drug is paid without PA. PA is only triggered when the T2DM ICD-10 code is absent from claims history. The policy explicitly states that drugs used for weight reduction/management, including antidiabetic drugs used off-label, are a standard exclusion for most benefits. Mounjaro has not been studied in combination with short-acting, medium-acting, or dual formulation insulins.
Policy effective March 17, 2026 · verified June 3, 2026 · source: Antidiabetic GLP-1 Receptor Agonists And Gip GLP-1 Receptor Agonists · View policy document (PDF)