Drug coverage reference
Mounjaro coverage & prior authorization
Mounjaro is tirzepatide (GLP-1/GIP), FDA-approved for type 2 diabetes. Self-administered, so it's a pharmacy-benefit (Part D / NCPDP) drug — there is no national HCPCS J-code, and an office-administered medical claim will deny.
Last verified · Reviewed by the D3rx Clinical Billing Team. Coverage shifts fast — confirm against the plan policy.
Does your payer cover Mounjaro?
| Payer | Mounjaro coverage |
|---|---|
| Aetna | Covered with prior authorization |
| UnitedHealthcare | Covered with prior authorization |
| Cigna | Covered with prior authorization |
| Humana | Covered with prior authorization |
| Anthem (Elevance Health) | Covered with prior authorization |
| Blue Cross Blue Shield of Illinois | Covered with prior authorization |
| Blue Cross Blue Shield of Texas | Covered with prior authorization |
| California Medi-Cal (Medi-Cal Rx) | Covered with prior authorization |
| Texas Medicaid | Covered with prior authorization |
| New York Medicaid (NYRx) | Covered with prior authorization |
| Florida Medicaid | Covered with prior authorization |
Each links to Mounjaro's source-cited prior-authorization criteria for that payer.
Diagnosis codes for Mounjaro
Diagnosis codes determine GLP-1 coverage. Diabetes use: E11.- (type 2 diabetes; e.g. E11.9 without complications, E11.65 with hyperglycemia). Weight-loss/obesity use: E66.9 (obesity, unspecified), E66.01 (morbid/severe obesity due to excess calories), E66.3 (overweight), PLUS a Z68.- BMI code (Z68.30-Z68.45 for adult BMI ≥30; e.g. Z68.41 = BMI 40.0-44.9) that many payers require. OSA (Zepbound): G47.33. Wegovy CV indication: established-CVD codes (e.g. I25.-) with overweight/obesity. Comorbidities for the BMI≥27 pathway: I10 (HTN), E78.- (dyslipidemia), E11.- (T2DM), G47.33 (OSA).
Frequently asked
- Is Mounjaro covered for type 2 diabetes?
- Mounjaro (tirzepatide) is FDA-approved for type 2 diabetes. Medicare Part D and Medicaid cover GLP-1s for type 2 diabetes (subject to formulary + PA), and commercial plans generally cover them with prior authorization. Confirm the specific plan's formulary and PA criteria.
d3rx does not hold plan-specific pharmacy formularies or PBM prior-auth grids, so it cannot confirm a particular plan's GLP-1 coverage, tier, or PA criteria. The guidance below is the general, source-cited rule; confirm the specific plan's pharmacy formulary / PA policy for a binding answer.
Get a payer-specific Mounjaro answer
Check Mounjaro against a specific payer in the GLP-1 PA lookup, or ask Ask D3 — free, cited, no signup.