Mounjaro (tirzepatide) is a prescription medication used to manage type 2 diabetes and sometimes prescribed off-label for weight loss. Its high cost, often over $1,000 per month without insurance, makes understanding insurance coverage crucial.
This article explains what insurance pays for Mounjaro, including private plans, Medicare, Medicaid, and savings options. We’ll use simple language to help you navigate costs and coverage.
What Is Mounjaro?
Mounjaro is an injectable drug approved by the FDA in 2022 for adults with type 2 diabetes. It mimics two hormones, GLP-1 and GIP, to control blood sugar and slow digestion. Many users also experience weight loss, leading to off-label use for weight management. A single month’s supply (four pens) can cost $1,000 to $1,500 without insurance.
The same active ingredient, tirzepatide, is in Zepbound, which is FDA-approved for weight loss. Insurance coverage often depends on whether Mounjaro is prescribed for diabetes or weight loss. Knowing your plan’s rules is key to understanding what insurance pays for Mounjaro.
Why Is Insurance Coverage Important?
Mounjaro’s list price is around $1,069 per month, making it unaffordable for many without insurance. Insurance can lower costs to as little as $25 per month for some users. Coverage varies by plan, diagnosis, and whether prior authorization is needed. Without insurance, long-term use can cost over $12,000 annually.
Understanding what insurance pays for Mounjaro helps you budget and avoid surprise expenses. It also guides discussions with your doctor about affordable alternatives. Let’s explore how different insurance types cover Mounjaro.
Private (Commercial) Insurance Coverage
Most private insurance plans cover Mounjaro when prescribed for type 2 diabetes, its FDA-approved use. Coverage is less likely for off-label weight loss use. Plans often list Mounjaro as a tier 3 or 4 drug, meaning higher copays. Copays typically range from $25 to $150 per month, depending on your plan.
Some plans require prior authorization, where your doctor submits proof of medical necessity. Step therapy may also be required, meaning you try cheaper drugs first. Check your plan’s formulary to confirm coverage and costs.
Mounjaro Savings Card
Eli Lilly, Mounjaro’s manufacturer, offers a savings card for commercially insured patients. Eligible users with type 2 diabetes can pay as little as $25 for a 1-, 2-, or 3-month supply. The card offers up to $1,800 in annual savings but isn’t available for Medicare or Medicaid users. You can apply online or call 1-844-805-5807 to check eligibility.
This program significantly reduces out-of-pocket costs. However, your plan must cover Mounjaro, and you need a diabetes diagnosis. Always verify eligibility before relying on the savings card.
Medicare Coverage for Mounjaro
Medicare Part D and Medicare Advantage plans often cover Mounjaro for type 2 diabetes. Coverage depends on your plan’s formulary, with Mounjaro typically on tier 3, leading to copays of $10 to $50 per month. Prior authorization is common, requiring your doctor to confirm medical necessity.
Medicare does not cover Mounjaro for weight loss, as weight loss drugs are generally excluded. If you’re in the deductible stage, you may pay the full cost (around $1,000) until your deductible is met. After that, copays apply until you reach the coverage gap.
Coverage Gap and Catastrophic Stage
In the Medicare coverage gap (donut hole), you pay a percentage of Mounjaro’s cost, often 25%. Once you reach catastrophic coverage, copays drop to a small amount or zero. Check your plan’s summary of benefits to estimate costs. Contact Medicare at 1-800-MEDICARE for details.
If Mounjaro is too costly, ask your doctor about generics like metformin. These may be covered with lower copays. Comparing plans during open enrollment can also save money.
Medicaid Coverage for Mounjaro
Medicaid coverage for Mounjaro varies by state, as each state sets its own drug formulary. Most states cover Mounjaro for type 2 diabetes, but prior authorization or step therapy is often required. Copays are usually low, ranging from $0 to $20, depending on income.
Weight loss use is rarely covered, as Medicaid typically excludes weight loss drugs. In 2022, Medicaid spent $30 million on Mounjaro, showing some coverage for diabetes. Contact your state’s Medicaid office to confirm if your plan covers Mounjaro.
State-Specific Rules
Some states classify Mounjaro as a non-preferred drug, requiring you to try preferred options first. Others may limit coverage to specific diagnoses. For example, a patient with diabetes and heart failure might face coverage denials if Mounjaro isn’t deemed necessary. Always check your state’s Medicaid website for details.
If coverage is denied, you can appeal with your doctor’s help. Provide medical records to prove Mounjaro’s necessity. Exploring state pharmaceutical assistance programs may also help.
What If Insurance Doesn’t Cover Mounjaro?
If your insurance doesn’t cover Mounjaro, you’ll pay the full retail price, around $1,069 per month. This is common for off-label weight loss use or if your plan excludes Mounjaro. There are ways to reduce costs, even without insurance. Below are some options:
- Prescription Discount Cards: Programs like GoodRx or SingleCare can lower costs to $935–$1,000 per month.
- Pharmacy Shopping: Prices vary by pharmacy, so compare costs at local and online pharmacies.
- Manufacturer Assistance: Eli Lilly’s Lilly Cares program may help uninsured, low-income patients, though Mounjaro isn’t always included.
- Alternative Drugs: Ask your doctor about cheaper options like metformin or other GLP-1 drugs.
These strategies can make Mounjaro more affordable. However, long-term costs may still be high without insurance.
Table: Insurance Coverage for Mounjaro by Type
| Insurance Type | Coverage for Diabetes | Coverage for Weight Loss | Typical Copay | Notes |
|---|---|---|---|---|
| Private Insurance | Usually covered | Rarely covered | $25–$150 | May require prior authorization |
| Medicare Part D | Often covered | Not covered | $10–$50 | Prior authorization common |
| Medicaid | Varies by state | Rarely covered | $0–$20 | Step therapy or appeals may be needed |
| No Insurance | Not applicable | Not applicable | $935–$1,500 | Discount cards can lower costs |
This table summarizes what insurance pays for Mounjaro. Always verify with your provider for exact costs.
Alternatives to Mounjaro
If Mounjaro isn’t covered or is too expensive, other drugs may work for diabetes or weight loss. Zepbound, with the same active ingredient, is FDA-approved for weight loss and may be covered for that use.
Other GLP-1 drugs like Ozempic or Trulicity might have better coverage. Generic drugs like metformin are often cheaper and widely covered.
Talk to your doctor about alternatives that fit your budget and health needs. They can also help with prior authorization or appeals if Mounjaro is the best option. Exploring all options ensures you get effective treatment.
How to Check Your Coverage
To find out what insurance pays for Mounjaro, follow these steps:
- Review Your Formulary: Check your plan’s drug list online or call customer service.
- Contact Your Insurer: Ask if Mounjaro is covered, what copays apply, and if prior authorization is needed.
- Talk to Your Doctor: They can confirm if Mounjaro is necessary and handle paperwork.
- Check Savings Programs: Visit Eli Lilly’s website for the Mounjaro Savings Card or other assistance.
These steps clarify your costs and coverage. Acting early prevents delays at the pharmacy.
Tips to Lower Mounjaro Costs
Reducing Mounjaro’s cost is possible with planning. Use the Mounjaro Savings Card if eligible. Compare prices at pharmacies using GoodRx or SingleCare. Ask your doctor about mail-order pharmacies, which may offer 90-day supplies at a discount. If uninsured, explore nonprofit assistance programs for prescription help.
Appealing insurance denials can also work. Your doctor can submit evidence of medical necessity. Staying proactive keeps costs manageable and ensures access to Mounjaro.
Summary
Mounjaro is a powerful drug for type 2 diabetes and weight loss, but its high cost makes insurance coverage essential.
Private insurance often covers it for diabetes with copays of $25–$150, while Medicare and Medicaid may cover it with restrictions.
Weight loss use is rarely covered, leaving patients to pay $1,000 or more monthly without insurance. Savings cards, discount programs, and appeals can lower costs. Contact your insurer and doctor to understand what insurance pays for Mounjaro and explore affordable options.
FAQ
What insurance pays for Mounjaro for type 2 diabetes?
Most private plans, Medicare Part D, and some Medicaid plans cover Mounjaro for diabetes. Copays range from $10–$150, but prior authorization may be needed. Check your plan’s formulary for details.
Does insurance cover Mounjaro for weight loss?
Insurance rarely covers Mounjaro for weight loss, as it’s off-label. Zepbound may be covered for weight loss instead. You may pay $1,000+ monthly without coverage.
How can I lower Mounjaro costs with insurance?
Use the Mounjaro Savings Card for copays as low as $25. Compare pharmacy prices and ask about mail-order options. Ensure prior authorization is completed.
What if my insurance denies Mounjaro coverage?
Appeal the denial with your doctor’s help, providing medical records. Explore discount cards like GoodRx or alternatives like metformin. Contact Eli Lilly for assistance programs.
Does Medicare cover Mounjaro for diabetes?
Many Medicare Part D plans cover Mounjaro for diabetes, with copays of $10–$50. Prior authorization is often required. Weight loss use is not covered.