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Why won t my insurance pay for Mounjaro?

drugs.com - Is Mounjaro covered by insurance or Medicare? - Drugs.com

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Your insurance coverage for Mounjaro will vary based on your insurance plan and drug benefits. To find out if your drug plan will pay for Mounjaro, contact your drug benefit company and ask if Mounjaro is on their formulary. Since it is a new medication, most insurance companies do not cover Mounjaro yet, but there are ways to save. The manufacturer of Mounjaro offers a savings card that can lower your cost to $25 for up to a 3-month supply, if you have commercial prescription insurance and a documented diagnosis of type 2 diabetes. Patients covered under government insurance such as Medicare or Medicaid do not qualify for the $25 savings card. The amount you pay for Mounjaro will depend upon your prescription drug coverage, deductible and copay (determined by the “tier”). Higher tiers, like tier 3 or 4, usually mean higher copays. If you have not fully met your yearly deductible, or if the drug is not covered, you may be responsible for the full monthly cost of this drug, which may be over $900. Coverages will vary among plans. Mounjaro (tirzepatide) is a new medicine approved by the FDA in May 2022 to help lower blood sugar in adult patients with type 2 diabetes. It is used in addition to a weight-loss diet and exercise. Mounjaro is not yet approved as a weight loss medication, but it may help you lose weight if you have type 2 diabetes. It is given as a weekly subcutaneous (under the skin) injection. You can learn to administer this medicine for home use.

How do I get the Mounjaro savings card?

Eli Lilly, the manufacturer of Mounjaro offers a savings card program for eligible patients with commercial prescription drug insurance, even if your insurance plan does not cover Mounjaro. You may pay as little as $25 for up to a 3-month prescription (up to 12 pens). Commercial insurance is the type often offered through your employer or bought through the Marketplace at Healthcare.gov.

Related: Mounjaro Price Guide and Savings Coupons

If you have type 2 diabetes and are an adult resident of the U.S., you may be able to save money with Mounjaro by using this savings card. You can obtain and activate the savings card on the Mounjaro website before you use it, or you can call Eli Lilly at 1-844-805-5807. If you do not have prescription insurance or you have government-sponsored insurance (such as Medicare, Medicaid, Medicare Part D, Medigap, DoD, VA, TriCare/Champus, or any state or pharmaceutical assistance program), you are not eligible for the $25 Mounjaro prescription drug savings card.

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How long does the Mounjaro savings card last?

If your insurance covers Mounjaro and you are eligible, you can use the Mounjaro savings card until Dec. 31, 2023 OR for up to 24, one-month fills (4 pens each fill), whichever comes first. If you have commercial prescription insurance and are eligible, but your insurance does NOT cover Mounjaro, this offer is good until June 30, 2023 for up to 12 one-month fills (4 pens each fill), whichever comes first. The total insurance drug cost picked up by the manufacturer for the savings card program is a maximum of $250 or $500 per month and a separate annual cap of $3,000. You are responsible for any costs that exceed the monthly or annual costs. If you do not have commercial insurance, but need assistance, you can call The Lilly Answers Center (TLAC) at 1-800-LillyRx (1-800-545-5979) for additional information on other types of payment options.

Will insurance pay for Mounjaro for weight loss?

Mounjaro is not yet approved as a weight loss medication, and insurance companies will not typically cover any cost for this use, even if your doctor writes you a prescription for weight loss (known as an “off-label” indication). Studies are ongoing for the Mounjaro approval for weight-loss, and results show it is very effective. Mounjaro (tirzepatide) has led to about 21% to 22.5% weight loss at the highest dose, in investigational clinical trials for weight management. These numbers approach what is seen with bariatric (weight loss) surgery.

Learn more: Does Mounjaro work for weight loss?

Other FDA-approved options similar to Mounjaro are available for weight loss. Wegovy (generic name: semaglutide) is an FDA-approved for the weight loss that is similar to, but not exactly the same as Mounjaro. Semaglutide is also sold under the brand names Ozempic and Rybelsus for type 2 diabetes in the U.S.

How do I get insurance to cover Mounjaro?

If your doctor agrees Mounjaro is right for you, and your insurance pays for Mounjaro, you may have to follow a “stepped therapy” plan for type 2 diabetes treatment before you are eligible for coverage. The specifics for these plans may vary among insurance companies. Your doctor may need to fill out a “prior authorization” form, which is paperwork submitted to the insurance company to determine your eligibility for Mounjaro. It can take several days or longer to hear the decision.

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Drug plans may require you to have previously had an inadequate response to several different types of 2 diabetes treatments (called “stepped therapy”), or experienced intolerable side effects, before you are eligible for Mounjaro treatment.

How much does one month of Mounjaro cost?

The list price for Mounjaro is about $974 for a one month (28-day) supply of Mounjaro (equal to four pens) as of December 2022, but most people do not pay this price. The price you pay is dependent on your insurance coverage, deductibles and copays. The manufacturer may be able to offer a $25 savings card or patient financial assistance, if you qualify. Pricing for specific insurance plans is not yet available, according to Eli Lilly, the manufacturer of Mounjaro. Eli Lilly has stated they will share the average out-of-pocket costs for patients once they become available in 2023. In general, Medicare Part D prescription drug plans and state Medicaid plans do not cover the cost of Mounjaro at this time, but an accepted prior authorization may allow coverage for the patient.

Is Mounjaro available as a generic?

No, Mounjaro (generic name: tirzepatide) was approved in 2022 and a generic option is not expected before 2036. Mounjaro is an expensive injectable medicine used weekly to help lower blood sugar levels in adults with type 2 diabetes. This is not all the information you need to know about Mounjaro (tirzepatide) for safe and effective use and does not take the place of your doctor’s directions. Review the full product information and discuss this information and any questions you have with your doctor or other health care provider.

drugs.com - Is Mounjaro covered by insurance or Medicare? - Drugs.com

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