Does Humana Cover Mounjaro? Criteria, Copay, How to Appeal

Medicare Part D plans cover Mounjaro for type 2 diabetes. Mounjaro is approved for type 2 diabetes and heart risk, not weight loss, so the plan judges it on those uses.

For type 2 diabetes: Covered by Part D plans
Prior authorization: Required
For weight loss: Bridge program only

A quick look at Mounjaro

How long it remains in your body

Its half-life is about 5 days. After 5 d, half is gone, and about 3% remains after five half-lives (25 d).

Weight loss in its main trial

In the 40-week SURPASS-1 trial for type 2 diabetes, people lost 7.8 kg, compared with 1 kg on placebo.

Costs over time

Monthly prices in US dollars include the list price and self-pay offers. Each price comes from the maker's price page.

Sources: FDA label (DailyMed), healthsystemtracker.org, pricinginfo.lilly.com.

Does Humana's coverage include Mounjaro?

Humana and Mounjaro
Medicine	Approved for	Status	Prior authorization
Mounjaro	Type 2 diabetes and heart risk	Covered by Part D plans	Required

Sources: pricinginfo.lilly.com, mounjaro.lilly.com, GoodRx.

The published policy

Humana is an insurer that offers Medicare Advantage

Read the policy yourself: humana.com.

A prior authorization checklist

Diagnosis: Your records show type 2 diabetes or heart risk. Heart risk is another approved use of Mounjaro.
Records: Include your recent A1C results and the diabetes drugs you have already tried.
Who files it: Your prescriber submits the prior authorization, not you.

If you are denied: how to appeal the decision

Denial reasons and what to do
Denial reason	What to send or ask
Prior authorization missing	The plan's form comes from your prescriber, along with your type 2 diabetes diagnosis and a recent A1C.
The plan wants another drug first	Ask the plan which drugs it wants you to try first, and send the records of the drugs you have tried so far.
The drug is not on the plan's list	Ask for a formulary exception, and find out which GLP-1 the plan prefers instead.

Get the denial letter, since it names the exact rule that was not met.
Include chart notes that answer the rule with the appeal. Your prescriber files the appeal.
If the plan's own appeal fails, request an external review from an independent reviewer.

What changes by state and plan

Mounjaro coverage with other plans
Plan	For type 2 diabetes	Prior authorization
Medicare	Covered by Part D plans	Required
Medicaid	Covered	Required
Cigna (Evernorth / Express Scripts)	Covered on formulary	Required
Blue Cross Blue Shield	Covered on formulary	Required
Kaiser Permanente	Covered on formulary	Required
CVS Caremark	Covered on formulary	Required
TRICARE	Covered with PA	Required
Navitus	Covered on formulary	Not listed
Aetna	Covered on formulary	Required
UnitedHealthcare (Optum Rx)	Covered on formulary	Required
Express Scripts	Covered on formulary	Required
Optum Rx	Covered on formulary	Required
VA (Veterans Health Administration)	Covered	Required
GEHA	Covered	Required
Ambetter (Centene)	Covered on formulary	Required
ACA Marketplace plans	Common	Required
Amerigroup (Elevance Medicaid)	Covered with PA	Required