How to get Mounjaro covered by insurance?

Weight loss medications, like Mounjaro (tirzepatide), can be life-changing for individuals struggling to lose weight. These medications can help regulate blood sugar levels, control hunger, and even lead to significant weight reduction.

But, they can also be incredibly costly, especially when they are prescribed off-label. Many insurance plans don’t automatically cover these prescriptions, leaving patients with hefty out-of-pocket expenses.

Are there steps you can take to help make Mounjaro for weight loss more affordable? Is Mounjaro insurance coverage possible?

Why do you need Mounjaro insurance coverage for weight loss?

Without insurance coverage, Mounjaro can be incredibly expensive, with out-of-pocket costs reaching over $1000 per month. These steep prices can make it difficult, if not impossible, for many individuals to access this medication long-term.

Mounjaro price without insurance

The cost of Mounjaro without insurance is a significant barrier for many individuals. With the current list price at $1,069.08 per fill, the out-of-pocket expense can be overwhelming. For those who need to use Mounjaro long-term, this can add up quickly with costs totaling $12,828.96 per year.

Mounjaro cost with insurance

If you have an insurance that covers Mounjaro, or one that allows for approval through prior authorization or step therapy, it can significantly lower your monthly out-of-pocket costs.

Costs will vary depending on the insurance plan, coverage options, and diagnosis. For instance, you may be eligible to pay as little as $25 for a 1- or 3-month prescription if you have commercial insurance and a prescription consistent with FDA-approved product labeling.

Since Mounjaro is still a relatively new FDA-approved medication, the manufacturer (Eli Lilly) does not currently have data on specific insurance plan pricing. You will need to contact your insurance company to get a better understanding of out-of-pocket costs.

Is Mounjaro covered by insurance?

Mounjaro has shown impressive weight loss results for individuals with a BMI over 30, with an average 20.9% weight loss (up to 26% with diet and exercise). While its weight loss benefits are impressive, this brand name is not FDA-approved for weight loss.

Most insurance providers are hesitant to cover medications prescribed off-label. This means that when it’s prescribed off-label for weight loss, insurance companies are less likely to cover it, leaving patients responsible for the full cost.

Is Mounjaro covered by insurance? The answer is: unlikely.

What insurance covers Mounjaro for weight loss?

There is no easy to find list of insurance companies or plans that provide Mounjaro insurance coverage for weight loss. While many will cover Mounjaro for diabetes management, fewer will provide coverage for the off-label use of weight loss.

You can review your current plan and your company’s prescription “formulary,” which lists covered medications and whether or not they have specific eligibility requirements. But, you may still have to reach out to your insurance provider to get a clearer answer on whether or not they provide coverage for weight loss.

How to get Mounjaro insurance coverage: step-by step guide

There is no guarantee that your insurance provider will cover Mounjaro for weight loss. But, there are strategies you can follow to improve your chances of securing coverage and reducing out-of-pocket costs.

1. Review Your Current Plan

The first step to get Mounjaro covered by insurance is simple—in theory. You need to review your current insurance plan and its specific coverage details. This information should be openly available to you through your insurance app or the provider’s website.

You will be able to access your plan’s formulary. This should be a searchable list of all medications covered under your plan. Here is where things get a little tricky. Mounjaro may be listed as a covered medication—but this will likely be for diabetes management.

Look for special requirements. Some insurance plans will approve certain medications if certain conditions are met. Usually this means prior authorization or step therapy.

If the formulary does not explicitly mention Mounjaro for weight loss, you will need to reach out to your provider for further clarification.

2A. Submit a Prior Authorization Claim

If your insurance provider is willing to provide Mounjaro insurance coverage for weight loss with prior authorization, you will need to prove medical necessity.

You will need to work with your healthcare provider to gather all the necessary documentation and submit it to the insurance company for review. You will need documentation of your:

Medical history
Diagnosis
Comorbidities (such as type 2 diabetes, heart disease, etc.)
Previous weight loss treatments
Anything else your insurance company requires

2B. Apply for Step Therapy

Some insurance companies will require step therapy before providing insurance coverage. Step therapy requires patients to begin with less expensive or more established medications before approving the requested treatment.

Reach out to your insurance company to determine what the required first-line treatment and additional steps (if any) will be.

3. Prepare for Appeals

It is always possible your initial request will be denied. You do have the right to appeal the decision. But, you will need to provide further evidence to support the medical necessity of the treatment.

Submit the appeal promptly and follow up with your insurance company to ensure it’s being reviewed.

What to do if I can’t get my Mounjaro covered by insurance?

There is a chance that your insurance provider will still not offer Mounjaro insurance coverage. If this happens, you have two main options: change providers, or choose a Mounjaro alternative.

Changing Insurance Providers

If you are going to change insurance providers, do your due diligence. This will require a bit of research and you will need to reach out to potential providers to confirm coverage of Mounjaro for weight loss.

Choosing a Mounjaro Alternative

You also have the option of choosing a Mounjaro alternative. The most popular alternative is Ozempic (semaglutide), which is also not FDA-approved for weight loss.

Zepbound (tirzepatide) and Wegovy (semaglutide) are FDA-approved for weight loss, but may still not be covered. Unfortunately, insurance companies are only required to provide obesity screening and counseling under the Affordable Care Act.

You also have the option of choosing a compounded medication to save on out-of-pocket costs.

Save money on the cost of Mounjaro without insurance

Even if you can’t secure insurance coverage for Mounjaro, there are still ways to save on the cost. Heally offers subscription plans to help you access Mounjaro at a lower price.

By registering with Heally, you can potentially reduce your out-of-pocket expenses and get started on your Mounjaro prescription more affordably. Don’t let high costs hold you back—sign up with Heally today!