Does Aetna cover Mounjaro for diabetes?

Are you wondering, “Does Aetna cover Mounjaro for diabetes?” Aetna usually covers Mounjaro (tirzepatide) for type 2 diabetes, but the insurance coverage details vary, based on the Aetna plan, and Mounjaro coverage requires a prior authorization.

During this guide, you’ll learn about eligibility criteria for coverage, how to know if your Aetna covers Mounjaro for diabetes, tips for improving your chances for approval, and more. Find a licensed provider on Klarity Health and get a telehealth appointment with a licensed healthcare provider within 24 hours.

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Does Aetna cover Mounjaro for diabetes?

Mounjaro is an injectable prescription medication approved by the U.S. Food and Drug Administration (FDA) to reduce blood sugar levels in people with type 2 diabetes. Type 2 diabetes is a chronic disease where your body doesn’t create enough insulin or can’t use the insulin it produces, which leads to increased blood sugar levels.

Mounjaro is part of a medication class called dual glucose-dependent insulinotropic polypeptide (GIP)/glucagon-like peptide-1 (GLP-1) receptor agonists. GIP is a hormone that stimulates insulin release from your pancreas when you consume glucose. GLP-1 is another hormone that stimulates insulin release, reduces blood sugar levels by suppressing glucagon secretion, and promotes feelings of fullness. Dual GIP/GLP-1 receptor agonists, such as Mounjaro, combine the effects of GIP and GLP-1 receptor activation to better control blood sugar levels in people with type 2 diabetes.

Wondering if Aetna covers Mounjaro for diabetes? Aetna insurance coverage for Mounjaro for diabetes varies, based on your plan and whether you fit the eligibility criteria for Aetna coverage.

Eligibility criteria for Aetna coverage for Mounjaro for diabetes

Aetna usually requires that you be diagnosed with type 2 diabetes and have documentation of an intolerance, inadequate response, or contraindication to preferred diabetes medication, such as liraglutide and Ozempic, to be approved for Mounjaro coverage.

Here are the specific eligibility criteria for Aetna coverage for Mounjaro for diabetes. You need to meet at least 1 of these criteria for coverage:

• A history of hemoglobin A1C (A1C) levels either at or over 6.5%. Your A1C levels reflect your average blood sugar, or glucose, levels over the past 2 to 3 months. The A1C test is an important tool for both diagnosing and managing diabetes. The test measures the percentage of red blood cells in your body that have glucose attached to them. If your A1C level is at or over 6.5%, that means you likely have type 2 diabetes.
• A 2-hour plasma glucose level during an oral glucose tolerance test (OGTT) that’s either at or over 200 milligrams per deciliter (mg/dL). The OGTT is a medical test that shows how well your body processes sugar or glucose. During the test, you need to drink a sugary solution and have your blood samples taken at certain times to measure your blood glucose levels and test for diabetes.
• Symptoms of hyperglycemia with a random glucose level either at or over 200 mg/dL. Also called high blood sugar, hyperglycemia is a health condition where you have too much glucose in your bloodstream. It’s considered a common feature of type 2 diabetes. Symptoms of hyperglycemia include urinating frequently, excessive thirst, frequent hunger, feeling tired, weight loss, dry mouth, and blurred vision. If you have symptoms of hyperglycemia and a random glucose level either at or over 200 mg/dL, it’s a strong indication that you have type 2 diabetes and qualify for Mounjaro for diabetes.

If you don’t meet these eligibility criteria, you might still be able to get Aetna coverage for Mounjaro for diabetes if you receive prior authorization. Your licensed healthcare provider can submit a prior authorization request for coverage if they believe you have type 2 diabetes and need the medication for diabetes.

How to know whether my Aetna covers Mounjaro for diabetes

Here are a couple of the best ways to figure out whether your Aetna plan covers Mounjaro for diabetes:

• Check the Aetna website or mobile app.
  • First, log in to your Aetna member account either through the secure website or mobile app.
  • Navigate to the Find a Medication tool, then search for Mounjaro or tirzepatide.
  • Review the coverage details for Mounjaro, including any restrictions or prior authorization requirements.
  • Check the website for potential cost information for Mounjaro for diabetes, including coinsurance or copays.
  • Check for information about retail pharmacy or mail-order options.
• Contact Aetna directly.
  • Find the Aetna customer service phone number on the website or on your member ID card.
  • Have your Aetna plan information and your member ID readily available to answer any questions about your coverage.
  • Explain to the customer service representative that you’re wondering about your Aetna coverage for Mounjaro for diabetes.
  • Ask the representative about specific details about coverage for Mounjaro for diabetes, including coinsurance, copays, restrictions, and prior authorization requests.
  • Ask whether Mounjaro for diabetes is covered by your specific Aetna plan.

Many health insurance plans, including Aetna plans, have certain criteria for covering Mounjaro, including a diagnosis of type 2 diabetes and documentation of trying and failing with other preferred medications for diabetes.

Weight loss is usually not a covered indication for Mounjaro under Aetna and other insurance plans. You might need prior authorization for Mounjaro for diabetes, which means your licensed healthcare provider needs to request approval from Aetna before you can get your prescription.

Does Aetna cover an online Mounjaro prescription for diabetes?

Whether Aetna covers an online Mounjaro prescription for diabetes depends on your particular Aetna plan and whether Mounjaro is considered medically necessary for you. You need to check your plan’s medication list or formulary. You might also need to get prior authorization for an online Mounjaro prescription for diabetes.

Why Aetna might deny Mounjaro coverage for diabetes

Aetna might deny Mounjaro coverage for diabetes for a few reasons:

• Not an FDA-approved indication. Mounjaro is only FDA-approved to treat type 2 diabetes in adults. If you want to use Mounjaro for an off-label use, like weight loss, Aetna will probably deny coverage for you. If you have type 1 diabetes, rather than type 2 diabetes, or if you have a history of pancreatitis, Aetna will likely deny coverage, since these conditions are not FDA-approved uses for Mounjaro.
• No prior authorization. Aetna sometimes requires prior authorization for Mounjaro for diabetes, which means your prescribing provider needs to offer information about your diagnosis and treatment plan to Aetna for medication approval. If the prior authorization isn’t completed or the information doesn’t meet Aetna’s eligibility criteria, they can deny the claim.
• Not a medical necessity. Aetna might deny coverage for Mounjaro for diabetes if they don’t consider it medically necessary for you, particularly if there are equally effective and less expensive medications available.
• Not in the formulary. Check the formulary for your specific Aetna plan. If Mounjaro isn’t listed as a covered medication in your specific plan, Aetna is more likely to deny coverage.

Tips for improving your chances of Mounjaro approval for diabetes

Here are a few tips for improving your chances of Mounjaro approval for diabetes:

• Type 2 diabetes diagnosis. The most important thing you need to have in hand to improve your chances of Mounjaro approval for diabetes is to have a confirmed diagnosis of type 2 diabetes from a licensed and board-certified healthcare provider. Mounjaro is FDA-approved to treat type 2 diabetes in adults.
• Document your previous diabetes treatment history. Many health insurance plans require step therapy. Step therapy is a strategy where you try other less expensive diabetes medications first before Mounjaro. They want documentation that you’ve tried other medications first, which have either failed or resulted in harsh, intolerable side effects. Common diabetes medications to try first include sulfonylureas, thiazolidinediones, metformin, and dipeptidyl peptidase IV (DPP-4) inhibitors. Make sure your medical documents clearly state the medications you tried, doses, treatment duration, and reasons for inadequate response or discontinuation.
• Emphasize the effectiveness of Mounjaro. Offer evidence of the effectiveness of Mounjaro, particularly if you’ve already started the medication, including blood glucose readings, A1C levels, or other metabolic markers. Your doctor’s medical records and lab results should also note your positive response to Mounjaro.

Alternatives and savings options if Aetna doesn’t cover Mounjaro for diabetes

If Aetna doesn’t cover Mounjaro for diabetes for you, you have several other options to consider:

• Explore alternative medications to Mounjaro. There are several other medications to consider besides Mounjaro for diabetes, including Zepbound, other GLP-1 receptor agonists, and other classes of diabetes medications.
  •  Zepbound also contains tirzepatide, the same active ingredient as Mounjaro, but the medication is FDA-approved for chronic weight management.
  • Other GLP-1 receptor agonists, such as Ozempic (semaglutide), Rybelsus (semaglutide), Bydureon BCise (exenatide), Byetta (exenatide), Victoza (liraglutide), and Trulicity (dulaglutide), are FDA-approved for type 2 diabetes. 
  • Other classes of diabetes medications include DPP-4 inhibitors (Januvia), SGLT2 inhibitors (Farxiga, Invokana, and Jardiance), and metformin (oral biguanide). 
• Savings programs and options. There are also many other savings options and programs if you can’t get coverage from Aetna.
  • Manufacturer savings cards. You might be eligible for manufacturer savings cards if you have commercial insurance. These cards can decrease your out-of-pocket costs for Mounjaro.
  • Prescription discount cards. Platforms like GoodRx and SingleCare provide free discount cards that can reduce the cost of Mounjaro at participating pharmacies.
  • Patient assistance programs (PAPs). Pharmaceutical manufacturers often offer these PAPs, which provide discounted or free medications to underinsured or uninsured people who meet the eligibility requirements.
  • Fill a 90-day supply. Getting a larger supply of Mounjaro can help lower the overall cost of the medication.
  • Community health centers offer affordable health care and typically have pharmacies that give you prescription medications either at lower costs or on a sliding scale based on your income.
• Appeal Aetna’s decision. Your licensed healthcare provider might be able to appeal Aetna’s decision to deny coverage by offering documentation that proves the medical necessity of Mounjaro for you. You can work with your provider to get documentation, including clinical notes and medical records, together to support your appeal.

How to get prior authorization from Aetna for Mounjaro for diabetes

Here’s what you need to do to get prior authorization from Aetna for Mounjaro for diabetes:

• Check the prior authorization requirements. First, you need to confirm through Aetna’s drug search tool or your Aetna plan’s formulary if Mounjaro for diabetes requires prior authorization for your particular Aetna plan.
• Get all the necessary documentation together. Work with your licensed healthcare provider to collect all of your medical records, including A1C levels and other relevant lab results and diagnostic test results. You also need documentation of your type 2 diabetes diagnosis, any previous diabetes treatments, and their outcomes and side effects.
• Have your provider submit the prior authorization request. Your licensed healthcare provider then needs to submit the prior authorization request either electronically or by phone. If your provider isn’t able to submit the request electronically, they can contact Aetna’s Precertification Department by using the phone number on your member ID card.
• Wait for a decision. Aetna usually processes prior authorization requests within 14 days or 2 weeks. Aetna will either approve or deny the request, or they might request additional information.

Key takeaways

Here are some of the key takeaways:

• Mounjaro is an injectable prescription medication approved by the FDA to reduce blood sugar levels in people with type 2 diabetes.
• Type 2 diabetes is a chronic disease where your body doesn’t create enough insulin or can’t use the insulin it produces, which leads to increased blood sugar levels.
• Aetna insurance coverage for Mounjaro for diabetes varies, based on your plan and whether you fit the eligibility criteria for Aetna coverage.
• Aetna usually requires that you be diagnosed with type 2 diabetes and have documentation of an intolerance, inadequate response, or contraindication to preferred diabetes medication, such as liraglutide and Ozempic, to be approved for Mounjaro coverage.
• Whether Aetna covers an online Mounjaro prescription for diabetes depends on your particular Aetna plan and whether Mounjaro is considered medically necessary for you.

Book an appointment on Klarity Health

Ready to get a prescription for Mounjaro for diabetes? With Klarity Health, getting a telehealth appointment with a licensed healthcare provider is fast, simple, and convenient. You can simply connect with a provider from your own home and receive quality medical care in as little as 24 hours. The Klarity Health platform connects you with board-certified healthcare providers who follow clinical guidelines.

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