Does Express Scripts Cover Mounjaro for Weight Loss? A 2025 Guide
Mounjaro, or tirzepatide, is a medication primarily for type 2 diabetes but often prescribed off-label for weight loss. Its high cost, $1,000–$1,500 monthly without insurance, prompts many to ask, does Express Scripts cover Mounjaro for weight loss?
This article explores Express Scripts’ 2025 coverage policies, requirements, and alternatives. Let’s break it down to help you navigate your options.
What Is Mounjaro?
Mounjaro is an injectable drug approved by the FDA in 2022 for type 2 diabetes. It mimics GLP-1 and GIP hormones to regulate blood sugar and reduce appetite. This makes it effective for weight loss, with studies showing 15–20% body weight loss in a year.
Without insurance, Mounjaro’s annual cost can exceed $17,000. This makes coverage through pharmacy benefit managers like Express Scripts critical. Understanding their policies is the first step to accessing it affordably.
The drug’s popularity for weight loss has grown, but off-label use complicates coverage. Let’s examine Express Scripts’ approach to Mounjaro.
Express Scripts Coverage Overview
Does Express Scripts cover Mounjaro for weight loss? Express Scripts, a leading pharmacy benefit manager, typically covers Mounjaro for type 2 diabetes but not consistently for weight loss. Coverage for weight loss depends on your specific health plan.
For diabetes, Mounjaro is often a Tier 2 or Tier 3 drug, requiring prior authorization. Copays range from $25–$100, based on the plan’s formulary. Weight loss coverage is less common, as Mounjaro isn’t FDA-approved for this use.
Check your plan’s formulary on the Express Scripts website or call customer service at 1-800-467-2006. This confirms coverage details and restrictions.
Why Weight Loss Coverage Varies
Express Scripts covers medications for FDA-approved indications, like type 2 diabetes for Mounjaro. Off-label use for weight loss requires specific plan provisions, as it’s not universally covered. This is due to cost and medical necessity concerns.
Mounjaro’s retail price, around $1,474 monthly, influences coverage decisions. Express Scripts may prioritize Zepbound, FDA-approved for weight loss with the same active ingredient. Employer plans often dictate whether weight loss drugs are included.
In 2025, some plans allow weight loss coverage for Mounjaro, but it’s not standard. Always verify your plan’s formulary for clarity.
Prior Authorization Requirements
Express Scripts often requires prior authorization for Mounjaro, especially for weight loss. Your doctor must submit proof of medical necessity, like a type 2 diabetes diagnosis or, for weight loss, a BMI of 30+ (or 27+ with conditions like hypertension). Documentation includes lab results or prior treatment failures.
The process can take 48 hours to a week. Without approval, coverage is denied, and you’ll pay full price. Your doctor’s thorough submission is key to approval.
Contact Express Scripts at 1-800-753-2851 to track your request. Approval can significantly lower your out-of-pocket costs.
Checking Your Plan’s Coverage
Log in to your Express Scripts account to view your plan’s formulary. Search for Mounjaro to see its tier, copay, and requirements. This shows if weight loss is covered.
Call Express Scripts customer service for detailed answers. Ask about Mounjaro for weight loss, prior authorization, and alternatives like Zepbound. They can clarify plan-specific rules.
If your plan is employer-sponsored, check with your HR department. They may know if weight loss drugs are included in your benefits.
Alternatives to Mounjaro
If Express Scripts doesn’t cover Mounjaro for weight loss, Zepbound is a viable alternative. It’s FDA-approved for obesity and uses tirzepatide, with some plans covering it after prior authorization. Copays vary by plan.
Other weight loss drugs, like Wegovy or Saxenda, may be covered, depending on your plan. These require similar criteria, such as a high BMI or obesity-related conditions. Discuss options with your doctor.
Non-drug options, like Express Scripts’ weight management program or covered diet plans, can support weight loss. These may be more accessible under your plan.
Mounjaro Savings Card
Eli Lilly offers a Mounjaro Savings Card for patients with commercial insurance. It can lower copays to $25 monthly for type 2 diabetes, but weight loss use may not qualify. Savings are capped at $473 per month.
Apply online at Eli Lilly’s website or through your doctor. Present the card at your pharmacy to reduce costs. It’s not valid for Medicare or Medicaid plans.
If Express Scripts covers Mounjaro, combining the savings card with your plan can minimize expenses. Verify eligibility for your prescription.
Patient Assistance Programs
Eli Lilly’s patient assistance program provides Mounjaro at low or no cost for low-income or uninsured patients. You must submit financial documents, like tax returns, and meet residency requirements. This is ideal if Express Scripts denies coverage.
Applications take weeks to process, but approval eliminates most costs. Call Eli Lilly at 1-800-545-5979 for details. Your doctor can help with the application.
This program ensures access to Mounjaro for those facing financial barriers. It’s a valuable option for long-term use.
Cost Comparison Table
The table below estimates Mounjaro costs with Express Scripts and other options in 2025. Prices vary by plan and pharmacy.
| Scenario | Estimated Monthly Cost | Notes |
|---|---|---|
| Express Scripts (Diabetes) | $25–$100 | Prior authorization, Tier 2/3 drug |
| Express Scripts (Weight Loss) | Not typically covered | Zepbound may be covered instead |
| No Insurance | $1,000–$1,500 | Full retail price, varies by pharmacy |
| Mounjaro Savings Card | $25–$500 | Commercial insurance, diabetes use |
| Patient Assistance Program | $0–$25 | Low-income, uninsured, application required |
Note: Prices are approximate. Confirm with Express Scripts or pharmacies for accuracy.
Tips to Secure Coverage
Here are practical steps to explore Mounjaro coverage with Express Scripts:
- Review your formulary on the Express Scripts website for Mounjaro’s status.
- Inquire about Zepbound for weight loss coverage options.
- Submit prior authorization with your doctor’s detailed documentation.
- Use the Mounjaro Savings Card to lower copays if eligible.
- Apply for patient assistance if coverage is denied or unaffordable.
These steps improve your chances of approval or savings. Keep records of all interactions. Combining strategies often yields the best results.
Appealing a Coverage Denial
If Express Scripts denies Mounjaro coverage, you can appeal. Contact Express Scripts to understand the denial reason, often lack of medical necessity or off-label use. Your doctor can submit additional evidence, like health records or lab results.
Follow the appeal process in your denial letter, typically requiring a written request within 60 days. Appeals may take weeks, so act promptly. Keep copies of all documents.
A successful appeal can unlock coverage or lower costs. Your doctor’s support is crucial for a strong case.
Other Cost-Saving Options
If Express Scripts doesn’t cover Mounjaro for weight loss, discount platforms like GoodRx or SingleCare can reduce costs to $900–$1,200 monthly. These work without insurance at many pharmacies. Compare prices online for the best deal.
Some pharmacies offer in-house discounts or price matching. Call local pharmacies to find the lowest price. This can help bridge the gap if coverage is limited.
In Canada, Mounjaro costs $240–$390 USD monthly, but importing requires a prescription and U.S. regulatory compliance. Verify pharmacy legitimacy before ordering.
Staying Informed
Express Scripts updates formularies annually, often in January. Check your plan during open enrollment or on their website for 2025 changes. Coverage for weight loss drugs may expand as demand grows.
Join online communities on platforms like X to learn from other Express Scripts members. They share tips on navigating coverage or finding discounts. This can reveal new strategies.
Your pharmacist can clarify copays or suggest savings options. Regular communication with your healthcare team keeps you prepared.
Summary
Does Express Scripts cover Mounjaro for weight loss? In 2025, Express Scripts typically covers Mounjaro for type 2 diabetes, requiring prior authorization and copays of $25–$100.
Weight loss coverage is not standard, as Mounjaro lacks FDA approval for this use, but some plans may allow it.
If denied, appeal with your doctor’s help, use the Mounjaro Savings Card, or apply for Eli Lilly’s patient assistance program. Explore alternatives like Zepbound or discounts like GoodRx. Staying proactive helps you manage costs and access effective treatment.
FAQ
Does Express Scripts cover Mounjaro for weight loss in 2025?
Express Scripts rarely covers Mounjaro for weight loss, favoring its use for type 2 diabetes. Check your plan’s formulary or ask about Zepbound, approved for obesity. Prior authorization is typically required.
What is needed for Express Scripts to cover Mounjaro?
For diabetes, a diagnosis and prior authorization are required. Weight loss may need a BMI of 30+ or 27+ with conditions. Your doctor submits documentation for approval.
Can the Mounjaro Savings Card help with Express Scripts?
Yes, the savings card can lower copays to $25 for diabetes with commercial insurance. Weight loss use may not qualify. Apply online at Eli Lilly’s website.
What if Express Scripts denies Mounjaro coverage?
Appeal with your doctor, providing medical evidence. Explore Zepbound, patient assistance programs, or GoodRx discounts. Discuss alternatives like Wegovy with your doctor.
Are there alternatives to Mounjaro with Express Scripts?
Zepbound, Wegovy, or Saxenda may be covered with prior authorization. Express Scripts’ weight management program or diet plans are other options. Consult your doctor for plan-specific details.
