Medicare's Coverage of Mounjaro

Medicare Part D (prescription drug coverage) covers Mounjaro, but whether your plan pays for it depends on your specific plan's formulary — the list of drugs your plan covers. Most major Medicare Part D plans do cover Mounjaro, but not all, and coverage rules vary. Your plan may require you to try other diabetes medications first, pay a higher copay, or get approval from your doctor before the pharmacy fills your prescription.

If you have Original Medicare (Part A and B) without Part D, Mounjaro is not covered. If you have a Medicare Advantage plan (Part C), check your plan documents or call the plan directly, because coverage varies widely. The cost to you depends on which plan you have, where you are in the coverage stages, and whether your doctor's request for coverage is approved.

Key Takeaways

  • Most Medicare Part D plans cover Mounjaro, but your specific plan may have restrictions like requiring you to try other medications first.
  • Your out-of-pocket cost depends on your plan's copay, deductible, and whether you have reached the coverage gap or catastrophic coverage stage.
  • Your doctor may need to submit a prior authorization request to your plan before the pharmacy can fill your prescription.
  • If your plan does not cover Mounjaro or the cost is too high, you can ask your doctor about other diabetes medications or contact your plan to appeal the decision.

How to Find Out What Your Plan Covers

The fastest way to know whether your plan covers Mounjaro is to call the customer service number on the back of your Medicare card. Have your card in front of you. Tell them you want to know if Mounjaro is on your plan's formulary and what your copay would be. They can also tell you if your doctor needs to submit a prior authorization.

You can also check your plan's website. Most plans post their formulary online as a searchable PDF or database. Search for "tirzepatide" (Mounjaro's generic name) or "Mounjaro" directly. If you cannot find it or do not use the internet, the customer service number is the most reliable option.

If you are shopping for a new plan during open enrollment, use Medicare.gov's Plan Finder tool. Enter Mounjaro and it will show you which plans in your area cover it and what the estimated cost would be under each plan.

Prior Authorization and Step Therapy Requirements

Many Medicare Part D plans require prior authorization before they will pay for Mounjaro. This means your doctor must submit a request to your plan explaining why you need this medication. The plan reviews the request and either approves it, denies it, or asks your doctor for more information. This process usually takes three to five business days.

Some plans also use step therapy, which means you may need to try and fail on other diabetes medications (usually metformin or a GLP-1 drug like semaglutide) before the plan will cover Mounjaro. Your doctor can request an exception if step therapy is not appropriate for your medical situation, but this takes longer — sometimes two to three weeks.

Ask your doctor's office to handle the prior authorization request. They have the forms and know how to submit them to your plan. If your plan denies coverage, your doctor can appeal or request an exception based on your health needs.

What You Will Pay Out of Pocket

Your cost for Mounjaro depends on where you are in your plan's coverage stages. Most people pay a copay each month — this might be $35, $50, $75, or more, depending on your plan and whether Mounjaro is in a higher tier. Some plans charge a percentage of the drug's cost (coinsurance) instead of a flat copay.

If you have not yet met your deductible for the year, you may pay the full price of Mounjaro until you do. Once you reach your plan's out-of-pocket limit, Medicare and your plan cover the rest of your prescription costs for the rest of the year.

Mounjaro's retail price is around $1,000 per month without insurance, but your plan negotiates a lower price. Even with a copay, your actual cost is much less. If the copay is still too high, ask your doctor if there are other options, or contact your plan to see if you can switch to a plan with lower copays during open enrollment.

What to Do If Your Plan Does Not Cover Mounjaro

If your plan's formulary does not include Mounjaro, you have several options. First, ask your doctor if there is a similar medication your plan does cover — other GLP-1 drugs like semaglutide (Ozempic) or dulaglutide (Trulicity) may work for your diabetes. Your doctor can also request a formulary exception, asking your plan to make an exception and cover Mounjaro anyway. Plans sometimes grant these if your doctor explains that other medications have not worked or caused side effects.

You can also appeal your plan's decision. Contact your plan's appeals department and ask for the formal appeals process. Your doctor's letter supporting the need for Mounjaro strengthens your appeal. If the appeal is denied, you can request an independent review through Medicare.

If you switch to a different Medicare Part D plan during open enrollment (October 15 to December 7 each year), you may find a plan that covers Mounjaro at a lower cost. Use Medicare.gov's Plan Finder to compare plans in your area.

Medicare Advantage Plans and Mounjaro

If you have a Medicare Advantage plan (Part C), coverage for Mounjaro varies by plan and by insurance company. Some Advantage plans cover it with a copay similar to Part D plans. Others may not cover it at all, or may require prior authorization and step therapy.

Call your Advantage plan's customer service number to ask about Mounjaro coverage. If your plan does not cover it or the copay is high, you can switch to Original Medicare with a Part D plan during open enrollment. This gives you access to more plans and potentially better coverage for Mounjaro.

Questions to Ask Your Doctor

Before your doctor prescribes Mounjaro, ask these questions to understand your coverage and costs:

  • Will you submit a prior authorization request to my insurance plan?
  • Does my plan typically cover Mounjaro, or do you know of any restrictions?
  • If my plan denies coverage, can you request an exception or appeal?
  • Are there other diabetes medications my plan covers that might work for me?
  • How much will Mounjaro cost me each month with my insurance?

Frequently Asked Questions

Does Original Medicare Part A and B cover Mounjaro?

No. Original Medicare Part A and B do not cover outpatient prescription drugs. You need Medicare Part D (prescription drug coverage) or a Medicare Advantage plan to have coverage for Mounjaro. If you have Original Medicare without Part D, you can enroll in a Part D plan during open enrollment or within 63 days of losing other drug coverage.

What if I cannot afford the copay for Mounjaro?

Talk to your doctor about other diabetes medications that may cost less. You can also ask your plan if there is a lower-cost tier available or if you can appeal to a lower copay. Some pharmaceutical companies offer copay information programs for people with Medicare, though may be able to access varies. Your doctor's office or pharmacist can help you find these programs.

Can I use a GoodRx coupon or discount card instead of my Medicare plan?

You should not use a discount card or coupon if you have Medicare. Using a non-Medicare discount can affect your plan's tracking of your out-of-pocket costs and may cause problems with your coverage later in the year. Always use your Medicare card at the pharmacy.

Will my copay change if I reach the coverage gap?

Yes. Once you and your plan have spent a certain amount on drugs in a year, you enter the coverage gap (also called the "donut hole"). In the gap, you pay a higher percentage of the drug's cost. Once you reach your plan's out-of-pocket limit, you move to catastrophic coverage and your copay drops again. Your plan's summary of benefits explains these stages and the amounts.

What happens if my plan stops covering Mounjaro next year?

Plans can change their formularies each year. If your plan removes Mounjaro from coverage, you can switch to a different Part D plan during open enrollment that does cover it. You can also ask your current plan why it removed the drug and request an exception. Your doctor can also appeal the decision on your behalf.