Medicare's Coverage of Mounjaro

Medicare Part D (prescription drug coverage) covers Mounjaro, but whether you pay nothing, a copay, or a percentage of the cost depends on which Part D plan you have and which tier your plan places the drug on. Mounjaro is a brand-name injectable medication for type 2 diabetes, and most Part D plans do cover it — but you will need to check your specific plan's formulary (the official list of drugs it covers) to know your out-of-pocket cost.

Medicare Part B does not cover Mounjaro. Part B covers injectable drugs that are administered in a doctor's office or hospital, but Mounjaro is a self-injected drug you use at home, so it falls under Part D instead. If you do not have Part D coverage, you may pay the full retail price, which is substantial.

Your actual cost will also depend on which stage of the Part D benefit year you are in. Early in the year, you may pay a copay or coinsurance. Once you reach the coverage gap (sometimes called the "donut hole"), your costs rise. Once you reach catastrophic coverage, your costs drop again. The exact amounts change each year.

Key Takeaways

  • Mounjaro is covered by most Medicare Part D plans, but you must check your plan's formulary to see what tier it is on and what you will pay.
  • Your out-of-pocket cost depends on your plan, the time of year, and which benefit stage you are in — not on Medicare itself.
  • If Mounjaro is not on your plan's formulary or is on a high tier, you can ask your doctor to request a coverage exception or switch to a different Part D plan during open enrollment.
  • GoodRx, manufacturer coupons, and patient information programs may lower your cost even if your Part D copay is high.
  • You should review your Part D plan's formulary every year, because drug tiers and coverage change annually.

How to Find Out What Your Plan Covers

The fastest way is to log into your Medicare plan's website and search the formulary for "Mounjaro" or "tirzepatide" (the generic name). The formulary will show you which tier the drug is on and what your copay or coinsurance will be. If you do not use the website, you can call the customer service number on the back of your Medicare card.

When you call or search, have your plan name and member ID ready. Ask specifically: "What tier is Mounjaro on?" and "What will I pay per month?" Some plans require prior authorization, meaning your doctor has to get approval from the plan before you can fill the prescription. Ask whether that applies to you.

If your plan does not cover Mounjaro at all, or if the copay is too high, you have options. You can request a coverage exception (sometimes called a formulary exception), which asks the plan to cover the drug even though it is not on the formulary. Your doctor will need to submit this request and explain why Mounjaro is medically necessary for you. The plan usually responds within 72 hours.

What Happens During the Coverage Gap

The coverage gap is a period in the Part D benefit year when you pay a higher percentage of the drug cost. In 2024, once you and your plan have spent $5,830 on covered drugs, you enter the gap. In the gap, you typically pay 25 percent of the cost of brand-name drugs like Mounjaro, while your plan pays the rest. This continues until your out-of-pocket spending reaches $7,050, at which point you move to catastrophic coverage.

These dollar amounts change each year, so check your plan's materials or Medicare.gov for the current year's thresholds. The gap can make expensive drugs like Mounjaro significantly more costly for a few months. If you know you will hit the gap, talk to your doctor about whether to pause treatment, switch to a different medication, or use a manufacturer coupon or patient information program to bridge the gap.

Manufacturer Coupons and Patient information Programs

Eli Lilly, the manufacturer of Mounjaro, offers a coupon program that can reduce your copay to as low as $25 per month for may be able to access patients. You can find this coupon on the Mounjaro website or ask your pharmacist. The coupon typically covers the difference between your copay and the $25 amount, so you pay $25 and the coupon covers the rest.

Eli Lilly also runs a patient information program for people without insurance or with high out-of-pocket costs. If your household income is below a certain threshold (which varies), you may receive Mounjaro for free or at a reduced cost. You will need to explore through the program and provide proof of income.

These programs have limits. The coupon usually cannot be used if you are in the coverage gap or catastrophic coverage phase, and some insurance plans do not allow coupons to be used at all. The patient information program has income limits and may have a waiting period. Ask your pharmacist or doctor's office to help you understand which programs you can use.

Switching Plans if Mounjaro Is Not Covered

If your current Part D plan does not cover Mounjaro or charges a very high copay, you can switch to a different plan during the Annual Enrollment Period, which runs from October 15 to December 7 each year. The new coverage starts January 1. You can compare plans on Medicare.gov by entering your zip code and the drugs you take.

When you compare plans, look at the total cost, not just the copay. Some plans have a lower copay for Mounjaro but a higher monthly premium. Others have a higher copay but a lower premium. Use the plan comparison tool to see the estimated yearly cost for your specific medications and usage.

If you miss the Annual Enrollment Period, you may still be able to switch if you have a may have access to life event — such as moving to a new state, losing other insurance, or having a significant change in income. Contact Medicare at 1-800-MEDICARE to ask whether you may have access to for a Special Enrollment Period.

What to Ask Your Doctor

Before you fill a Mounjaro prescription, ask your doctor these questions: "Will my insurance cover this, and do you know what my copay will be?" If your doctor's office has a staff member who checks insurance, they can often find this out before you leave. Ask: "If my plan does not cover it or the copay is too high, can you request a coverage exception?" and "Are there other diabetes medications my plan covers that might work for me?"

Also ask: "How much does this medication cost without insurance?" This helps you understand whether a manufacturer coupon or patient information program is worth pursuing. Finally, ask: "How long does it usually take for the insurance company to approve this medication?" This tells you whether to expect a delay before you can start treatment.

When to Contact Medicare Directly

Call Medicare at 1-800-MEDICARE (1-800-633-4227) if your plan denies coverage for Mounjaro and you believe the denial is wrong, or if you want to file a complaint about your plan's coverage. You can also call if you need help comparing plans or understanding your coverage options. Medicare staff can walk you through the coverage exception process and explain your rights.

If you are having trouble affording Mounjaro even with your Part D coverage, ask Medicare about the Extra Help program, which is a federal program that pays some or all of your Part D costs if your income and resources are below certain limits. You can explore through your local Social Security office or online at SSA.gov.

Frequently Asked Questions

Does Medicare Part B cover Mounjaro if my doctor gives it to me in the office?

No. Mounjaro is a self-injected drug, so it is covered under Part D (prescription drugs) even if you receive your first dose in a doctor's office. Part B covers injectable drugs that a healthcare provider administers, but Mounjaro does not fit that category. You will need Part D coverage to pay for it.

What if I cannot afford the copay even with a coupon?

Ask your doctor about other diabetes medications that your plan covers at a lower cost. Talk to your plan about a coverage exception. Contact Eli Lilly's patient information program to see if you may have access to based on income. You can also ask your doctor's office or a social worker whether there are local programs that help with medication costs.

Can I use a GoodRx coupon instead of my Medicare coverage?

You cannot use GoodRx at the same time as your Medicare Part D coverage. However, you can choose to pay cash and use a GoodRx coupon if the GoodRx price is lower than your Part D copay. Compare the two prices at the pharmacy before you decide which to use. Some pharmacies will not let you switch between them on the same prescription.

What if my plan's formulary changes and Mounjaro is no longer covered?

Plans can change their formularies during the year, though major changes usually happen at the start of the year. If Mounjaro is removed from your plan's formulary, you have the right to request a coverage exception. You can also switch to a different plan if the change happens during the Annual Enrollment Period. Contact your plan when ready if you notice a change.

Do I have to use a specific pharmacy to fill Mounjaro?

Most Part D plans cover Mounjaro at any pharmacy in their network, but some plans may have a preferred pharmacy or mail-order option with a lower copay. Check your plan's pharmacy network on your plan's website or call customer service. Using an out-of-network pharmacy will cost you more.