Medicare Part D covers Mounjaro, but only under specific conditions
Yes, Medicare Part D can cover Mounjaro (tirzepatide), the injectable medication for type 2 diabetes. However, your coverage depends on which Part D plan you have, whether your doctor's prescription meets your plan's requirements, and whether you have already met your deductible. Not every Part D plan covers it the same way, and some plans may require you to try other diabetes medications first before they will pay for Mounjaro.
Mounjaro is a newer medication, approved by the FDA in 2022. Because it is newer and more expensive than older diabetes drugs, Part D plans treat it differently than they treat standard medications. Your out-of-pocket cost can range from a small copay to hundreds of dollars per month, depending entirely on your specific plan and where you are in the coverage year.
Key Takeaways
- Medicare Part D plans do cover Mounjaro, but coverage rules vary by plan and change each year.
- Your plan may require prior authorization, meaning your doctor must get written approval from the insurance company before you fill the prescription.
- Some plans place Mounjaro on a higher cost tier, which means you pay more out of pocket than you would for older diabetes medications.
- You can call your Part D plan directly to find out your exact copay, whether prior authorization is needed, and what other medications your plan wants you to try first.
- Your costs change depending on whether you have met your deductible and which stage of the coverage year you are in.
How Part D plans decide what they cover
Each Medicare Part D plan creates its own list of covered medications, called a formulary. The formulary divides drugs into tiers, and your out-of-pocket cost depends on which tier your medication is on. Tier 1 drugs cost the least; Tier 5 drugs cost the most. Mounjaro typically lands on Tier 3 or Tier 4, meaning it is more expensive than basic diabetes medications but not the highest tier.
Plans also use prior authorization to control costs. This means your doctor must submit a request to the insurance company explaining why you need Mounjaro instead of a cheaper option. The plan reviews the request and either approves it or denies it. If approved, you can fill the prescription. If denied, you have the right to appeal, and your doctor can submit additional medical information to support the request.
Some plans also have a step therapy requirement, which means you must try one or more other diabetes medications first and show that they did not work well enough before the plan will cover Mounjaro. This can delay your access to the medication by weeks or months.
What your actual cost will be
Your out-of-pocket cost for Mounjaro depends on four things: your plan's copay or coinsurance for that tier, whether you have met your annual deductible, which stage of the coverage year you are in, and whether you may have access to for the Low-Income Subsidy program.
If you have not met your deductible yet, you typically pay the full price of Mounjaro until the deductible is satisfied. Once you meet the deductible, you pay your plan's copay or coinsurance for Tier 3 or Tier 4 drugs. In the coverage gap (sometimes called the "donut hole"), which occurs after you and your plan have spent a certain amount together, your costs jump again. After you reach the catastrophic coverage stage, Medicare pays most of the cost and you pay a small amount.
The monthly cost of Mounjaro without insurance is around $1,000 to $1,200 per month. With Part D coverage, your copay might be $35 to $150 per month, depending on your plan and where you are in the coverage year. If you may have access to for the Low-Income Subsidy, your copay may be as low as $1 to $5 per month.
How to learn about your specific plan covers Mounjaro
The fastest way is to call your Part D plan directly. The phone number is on the back of your Medicare card. Tell them you want to know about coverage for Mounjaro, and ask these specific questions: Is Mounjaro on your formulary? What tier is it on? What is your copay? Does the plan require prior authorization? Does the plan require step therapy?
You can also visit your plan's website and search the formulary yourself, though the website version may not be updated as quickly as the phone representative's information. If you do not yet have a Part D plan, you can view the formularies of different plans during the Annual Enrollment Period (October 15 to December 7 each year) on Medicare.gov.
Write down the answers you get, because you will need them when you talk to your doctor. If your plan denies coverage or requires step therapy, ask the representative how to appeal or what the next steps are.
What to do if your plan does not cover Mounjaro
If your current Part D plan does not cover Mounjaro, or if it requires step therapy that you do not want to do, you have options. During the Annual Enrollment Period (October 15 to December 7), you can switch to a different Part D plan that does cover Mounjaro. You can compare plans on Medicare.gov by searching for Mounjaro in the formulary search tool.
If you are outside the enrollment period and your plan just denied coverage, you may be able to request a Special Enrollment Period if your circumstances have changed. Your doctor can also request an exception to your plan's coverage rules, explaining why you specifically need Mounjaro instead of the medications your plan prefers.
Another option is to ask your doctor about the Mounjaro Savings Card, which is offered by the manufacturer (Eli Lilly). This card can reduce your copay to as little as $25 per month if you have commercial insurance, though it does not work with Medicare. Some people use it during the coverage gap stage when their Part D costs are highest, though you should ask your plan whether using the manufacturer's card affects your coverage year calculations.
Questions to ask your doctor before starting Mounjaro
Once you know your plan covers Mounjaro, talk to your doctor about whether it is the right medication for you. Ask whether your doctor thinks Mounjaro will work better than your current medication, what side effects to watch for, how often you will need to check in, and whether your doctor will handle the prior authorization request or whether you need to submit it yourself.
Also ask your doctor what to do if you have side effects, how long it usually takes to see results, and whether you will need to adjust other medications once you start Mounjaro. If your plan requires step therapy, ask your doctor whether they think you should try those other medications first or whether they recommend appealing the step therapy requirement.
When to contact Medicare or your plan
Contact your Part D plan when ready if you receive a denial letter for Mounjaro. You have 60 days to appeal. Contact Medicare (1-800-MEDICARE) if your plan is not responding to your appeal or if you believe the plan made an error in denying coverage.
If you are having trouble affording Mounjaro even with your Part D coverage, ask your doctor's office about patient information programs run by Eli Lilly. These programs can provide free or reduced-cost medication to people who meet income requirements, even if they have Medicare.
Frequently Asked Questions
Will my Part D plan cover Mounjaro if I use it for weight loss instead of diabetes?
No. Medicare Part D only covers Mounjaro when it is prescribed for type 2 diabetes. If your doctor prescribes it for weight loss alone, your Part D plan will not pay for it. You would need to pay the full price out of pocket or use a different insurance plan if you have one.
What happens to my Mounjaro coverage if I switch Part D plans?
Your coverage may change. A new plan might cover Mounjaro on a different tier, require prior authorization, or not cover it at all. You can only switch plans during the Annual Enrollment Period (October 15 to December 7) or if you may have access to for a Special Enrollment Period. Always check the new plan's formulary before you switch.
Can I get Mounjaro covered if I have Original Medicare without Part D?
No. Original Medicare does not cover outpatient prescription drugs. You must have Part D coverage or other prescription drug insurance. If you do not have Part D, you can enroll during the Annual Enrollment Period or within 63 days of losing other drug coverage.
Does my copay for Mounjaro count toward my out-of-pocket maximum?
Yes. Your copays and coinsurance for Mounjaro count toward your annual out-of-pocket maximum, which is set by Medicare each year. Once you reach that maximum, Medicare pays the full cost of your medications for the rest of the year.
What if my doctor says I need Mounjaro but my plan requires step therapy?
Your doctor can request an exception to the step therapy requirement by submitting a letter to your plan explaining why you specifically need Mounjaro instead of the medications the plan wants you to try first. This is called a formulary exception request. If the plan denies the exception, you can appeal.