Mounjaro (tirzepatide) has quickly become one of the most talked-about medications for people with type 2 diabetes. It helps lower blood sugar, promotes weight loss, and reduces heart disease risk in many patients. Because of these benefits, thousands of Medicare beneficiaries wonder if this expensive drug is covered under their plan.
The short answer is not simple. Coverage depends on your specific Medicare plan, how the drug is classified, and recent changes in Medicare rules. This guide explains everything clearly so you can understand your options in 2025.
We’ll look at original Medicare, Part D plans, Medicare Advantage, and new updates that may help more people get Mounjaro at a lower cost.
What Is Mounjaro and How Does It Work?
Mounjaro is an injectable medicine approved by the FDA in 2022 for adults with type 2 diabetes. It belongs to a class of drugs called GLP-1/GIP receptor agonists. Once a week, the injection helps the body release insulin when blood sugar is high and slows food leaving the stomach.
Many patients see A1C drops of 2% or more and lose 15–25 pounds in the first year. Doctors also prescribe the same drug under the brand name Zepbound for weight loss alone, but that version is treated differently by insurance.
Why Is Coverage So Confusing?
Medicare decides coverage based on whether a drug is medically necessary for an approved use. When Mounjaro first launched, many Part D plans placed it in Tier 4 or 5 (the most expensive tiers) or excluded it completely because it was new and costly.
In 2024 and 2025, Medicare made important changes to how obesity and weight-loss drugs are handled. These changes affect people who need Mounjaro for both diabetes control and significant weight loss.
Direct Answer: Does Medicare Cover Mounjaro for Type 2 Diabetes in 2025?
Yes, Medicare Part D and most Medicare Advantage plans with drug coverage now cover Mounjaro (tirzepatide) when it is prescribed for type 2 diabetes. Coverage became much more common starting January 2025 because of new federal guidance and negotiated drug prices.
However, you will still pay a portion of the cost unless you qualify for Extra Help or other assistance programs. Out-of-pocket costs vary widely from $25 to $550 per month after the deductible, depending on your plan and the coverage stage you are in.
How to Find Out If Your Specific Plan Covers Mounjaro
- Log into your Medicare.gov account or call 1-800-MEDICARE.
- Check your plan’s 2025 formulary (drug list) by entering “tirzepatide” or “Mounjaro.”
- Look at the tier and any requirements such as prior authorization or step therapy.
What If Your Plan Says “Not Covered” or Requires Prior Authorization
Many plans still require your doctor to prove that:
- You have a confirmed diagnosis of type 2 diabetes
- You tried and failed less expensive drugs like metformin or older GLP-1 drugs
- Your A1C remains above target despite other treatments
Your doctor submits a prior authorization form. Approval usually takes 3–14 days.
Costs You Can Expect in 2025
| Coverage Stage | Typical Cost for Mounjaro (per month) | Notes |
|---|---|---|
| Part D Deductible | Full price (~$1,000–$1,100) | Some plans have $0 deductible for preferred drugs |
| Initial Coverage | 25% coinsurance or fixed copay ($300–$550) | Depends on plan tier (usually Tier 3 or 4) |
| Coverage Gap (Donut Hole) | 25% of drug cost | In 2025, you pay only 25% for brand-name drugs in the gap |
| Catastrophic Coverage | $0 after reaching limit | Once out-of-pocket costs hit $8,000 (2025 threshold), no more copays |
| Extra Help (Low Income) | $4–$11 generic / brand copay | Automatic if you qualify for full Medicaid or SSI |
Medicare Advantage Plans and Mounjaro
About half of Medicare beneficiaries choose Medicare Advantage (Part C) plans. Most large Advantage plans from UnitedHealthcare, Humana, Aetna, and Cigna now include Mounjaro on their 2025 formularies when used for diabetes.
Some Advantage plans offer extra benefits like $0 copays for certain diabetes medications or over-the-counter allowances that can help pay for supplies.
New 2025 Changes That Help Patients
The Inflation Reduction Act continues to lower costs. Starting in 2025:
- Insulin copays stay capped at $35 per month
- The Part D deductible is capped at $590 (many plans are lower)
- The “donut hole” is smaller, and you pay only 25% for brand drugs
Eli Lilly, the maker of Mounjaro, also expanded its savings card program for Medicare patients who have commercial secondary insurance. If you have a Medigap plan or retiree coverage, you may pay as little as $25 per month.
Alternatives If Medicare Coverage Is Denied
If your plan still denies Mounjaro, talk to your doctor about:
- Trulicity (dulaglutide) – usually Tier 3 and cheaper
- Rybelsus (oral semaglutide) – the only GLP-1 pill
- Ozempic or Victoza – older injectables with proven coverage
You can also file an appeal with your Part D plan. About 50% of appeals are approved when proper medical records are submitted.
How to Lower Your Costs Even More
Apply for Extra Help through Social Security if your income is below 150% of the federal poverty level. In 2025, that means roughly $22,590 for a single person or $30,660 for a couple.
State Pharmaceutical Assistance Programs (SPAPs) in New Jersey, Pennsylvania, and several other states help Medicare beneficiaries pay Part D premiums and copays.
Patient assistance from Eli Lilly is limited for Medicare patients, but some nonprofit foundations still provide grants for diabetes medications.
Summary
In 2025, Medicare Part D and most Medicare Advantage plans do cover Mounjaro for type 2 diabetes. Coverage is no longer rare, but costs remain high for many people until they reach the catastrophic phase or qualify for Extra Help. Always check your specific plan’s formulary and ask your doctor about prior authorization requirements. With the right documentation and persistence, most patients with type 2 diabetes can get Mounjaro covered at an affordable price.
FAQ
What is the monthly cost of Mounjaro with Medicare Part D in 2025?
Costs usually range from $300 to $550 per month during the initial coverage period. Once you enter catastrophic coverage (after about $8,000 out-of-pocket), the copay drops to $0.
Can I use the Mounjaro savings card if I have Medicare?
Only if you have commercial secondary insurance. Pure Medicare patients generally cannot use manufacturer coupons, but some retiree plans allow it.
Is Mounjaro covered for weight loss only under Medicare?
No. Medicare still does not cover drugs when prescribed only for obesity, including Zepbound or Mounjaro used off-label for weight loss alone.
How long does prior authorization take?
Most plans decide within 72 hours for standard requests and 24 hours for expedited requests if your health is at risk.
Will coverage get better in 2026?
Possibly. Medicare is negotiating lower prices for tirzepatide starting in 2026, which should reduce list prices and patient copays even more.
What should I do if my plan denies coverage?
Ask your doctor to file an appeal with medical records showing why Mounjaro is medically necessary. Over half of appeals are approved.