Mounjaro (tirzepatide) is one of the most effective medications available today for type 2 diabetes and weight loss. Without insurance, a single month can cost $1,000–$1,300 out of pocket. Most patients want to know how to get Mounjaro covered by insurance so they can keep using it long-term without breaking the bank.
The good news is that coverage is improving quickly in 2025. Many major insurance plans now pay for Mounjaro when the right steps are followed. Success usually comes down to medical documentation, the correct diagnosis codes, and persistence.
This guide walks you through every proven method that patients and doctors use today to get approval, even when the first try is denied.
Why Insurance Companies Often Deny Mounjaro at First
Insurance companies look for two main things: a clear medical need and proof that cheaper drugs didn’t work. Mounjaro is still considered a “preferred” or “high-cost” drug on most plans. They require prior authorization (PA) almost every time.
Denials are common in the beginning, but 70–80 % of appeals are approved when the paperwork is done correctly. Knowing the rules makes a huge difference.
Direct Answer: How to Get Mounjaro Covered by Insurance
You get Mounjaro covered by having your doctor submit a strong prior authorization with the right diagnosis codes, proof of failed older medications, and current BMI or A1C numbers. Most plans cover it fully for type 2 diabetes and many now cover it for obesity or overweight with comorbidities in 2025.
Follow the exact steps below, and your chances of approval go above 85 % according to patient reports and specialty pharmacies.
Step 1: Get the Correct Diagnosis on Your Chart
Your doctor must list one of these on the prior authorization form:
- Type 2 diabetes (E11.9 or more specific codes)
- Obesity (E66.01) + at least one weight-related condition (high blood pressure, high cholesterol, sleep apnea, etc.)
- Overweight (BMI ≥ 27) + at least one comorbidity
Many denials happen because only “overweight” or “weight loss” is written. Insurance needs the official ICD-10 codes above.
Step 2: Complete Step Therapy (Try Cheaper Drugs First)
Most plans require 3–6 months of documented failure or side effects from at least two of these:
- Metformin
- Sulfonylureas (glipizide, glyburide)
- DPP-4 inhibitors (Januvia, Onglyza)
- SGLT2 inhibitors (Farxiga, Jardiance)
- GLP-1 drugs (Victoza, Trulicity, Bydureon)
Keep pharmacy records or doctor notes that show you tried them and still had high A1C or couldn’t lose weight.
Step 3: Submit Lab Work and Measurements
Include recent results (within 90 days):
- A1C above 7.0 % (for diabetes) or BMI ≥ 30 (or ≥ 27 with conditions)
- Blood pressure, lipid panel, or sleep study if using comorbidities
Step 4: Use the Right Prior Authorization Form and Letter of Medical Necessity
Your doctor should attach a short letter that says:
- Why older drugs failed or were not tolerated
- Your exact weight, BMI, and related health problems
- That Mounjaro is medically necessary to prevent heart disease, stroke, or diabetes complications
Many specialty pharmacies (AllianceRx, Accredo, CenterWell) provide pre-filled forms that are already accepted by most plans.
Step 5: Choose the Best Pharmacy and File Appeals Fast
Use a pharmacy that handles prior authorizations for you. If denied, appeal within 7–10 days with more records. Second-level appeals win most of the time.
Major Insurance Plans and Their 2025 Mounjaro Coverage
| Insurance Provider | Covers for Type 2 Diabetes | Covers for Weight Loss / Obesity | Typical Copay with Approval |
|---|---|---|---|
| UnitedHealthcare | Yes (Tier 3) | Yes if BMI ≥ 27 + comorbidity | $25–$100 |
| CVS Caremark (Aetna) | Yes | Yes in many states 2025 | $0–$75 |
| Express Scripts | Yes | Select plans only | $50–$200 |
| Cigna | Yes | Expanding in 2025 | $40–$150 |
| Blue Cross Blue Shield | Varies by state | Some states yes | $0–$300 |
| Medicare Part D | Yes (Tier 3–5) | No (obesity not covered) | $100–$500+ |
| Medicaid (state-dependent) | Usually yes | Some states yes | $0–$4 |
| OptumRx | Yes | Growing coverage | $50–$200 |
Extra Tips That Boost Approval Rates
Use the manufacturer savings card only AFTER insurance denies you. Combining both at the same time can cancel coverage.
Ask your doctor to write “Dispense as Written – Brand Medically Necessary” on the prescription. This blocks substitution with cheaper drugs.
Start the process 4–6 weeks before your current supply runs out. Prior authorizations can take 5–14 days.
Join patient assistance programs like LillyDirect if you have no insurance or very high copays.
What to Do If Your Job Changed Insurance or You Lost Coverage
File a new prior authorization immediately under the new plan. Most plans accept the same documentation you already gathered.
When Insurance Still Says No
Many people pay $550–$650 per month using the official Lilly savings card (if you have commercial insurance). Canadian pharmacies and compounding pharmacies are other options, but only use them after checking legality and safety in your state.
Summary
Getting Mounjaro covered by insurance in 2025 is very possible when your doctor uses the correct diagnosis codes, proves older drugs failed, and submits recent labs. Start with type 2 diabetes or obesity plus comorbidities for the highest success rate. Work with an experienced doctor and specialty pharmacy, file appeals quickly, and most patients end up paying $0–$100 per month instead of $1,200.
FAQ
Does every insurance plan cover Mounjaro in 2025?
No, but most large commercial plans do when prior authorization is approved. Medicare Part D covers only for diabetes, not weight loss.
How long does prior authorization take?
Usually 5–14 days. Expedited requests can be approved in 24–72 hours if your doctor marks it urgent.
Can I use the Lilly savings card and insurance together?
No. You must choose one. Use insurance first; switch to the card only if fully denied.
Will my doctor do all the paperwork?
Many will, especially endocrinologists and obesity medicine doctors. Some charge a small fee or send you to a specialty pharmacy that does it for free.
Is Mounjaro covered for weight loss without diabetes?
Yes on many UnitedHealthcare, CVS Caremark, and some BCBS plans if BMI is high and you have conditions like hypertension or high cholesterol.
What if I only have Medicare?
Coverage is possible for type 2 diabetes, but copays are often high ($300–$900) unless you have a supplement or Extra Help.
Can I appeal more than once?
Yes. First appeal, second appeal, and external review are allowed. Over 70 % of second appeals win.