What’s the Step Therapy Insurance Process for Mounjaro?

What is step therapy?

With step therapy, your insurance provider requires you to try a drug from its preferred medications list before it will cover a non-preferred drug.

Step therapy is also called “fail-first protocol.” This is because your insurance provider requires your doctor to confirm that one or more of the drugs on its preferred medications list were ineffective before it will cover certain other drugs. Preferred medications are often less expensive than non-preferred drugs.

The purpose of step therapy is to provide consumers with medications that work well and are safe and cost effective. However, step therapy is criticized by some as a way for insurance providers to spend less money.

Step therapy guidelines vary between insurance providers and states. Some private insurance plans may require step therapy for a certain medication, while others don’t. The majority of states now have laws that limit when an insurance provider can require step therapy. Contact your insurance provider for information about step therapy and your specific policy.

If you have Medicare or Medicaid, call the number on your membership card for details regarding whether step therapy applies to your medications. You can also visit the Medicare website or Medicaid website for this information.

In some cases, you may be able to skip the step therapy process if your doctor requests prior authorization. Your doctor may request prior authorization in the following situations:

• You’ve already tried a preferred drug while covered under another insurance provider.
• You can’t take a preferred drug due to an allergy or a history of severe side effects.
• Your doctor determines (for medical reasons) that you should try a non-preferred alternative.

Medical Perspective

If a person switches insurance plans, will they need to repeat the step-therapy process or lose coverage for their medication?

“Most plans do not guarantee treatment continuity, so a patient who switches insurers may need to meet the new plan’s prior authorization or step‑therapy rules even if they were already stable on their medication.

Many plans will approve continuation if there is documentation of clinical benefit, but this isn’t automatic and can still require a new authorization. It may help to ask the new plan or prescriber whether a “continuity of therapy” exception is available.”

— Andrew Cox, PharmD, MBA

» Learn more: How to Successfully Appeal an Insurance Denial

_{Quotes represent the opinions of our medical experts. All content is strictly informational and should not be considered medical advice.}

Does Mounjaro have a step therapy requirement?

Many health insurance companies have a step therapy requirement for Mounjaro.

For example, some plans may require you to first try a generic drug, such as metformin, to treat type 2 diabetes before it will cover Mounjaro (which is a brand-name drug).

In other cases, you may have to try a less expensive brand-name drug from your insurance provider’s preferred drug list before it will cover Mounjaro. To find out which drugs are preferred versus non-preferred, check your health plan documents or call your insurance provider.

It’s also important to note that your insurance provider may only cover Mounjaro if you’re using it to treat type 2 diabetes. The drug can also be prescribed off-label for weight loss.

Will my health insurance cover Mounjaro if it’s prescribed for weight loss?

Mounjaro is approved by the Food and Drug Administration (FDA) for managing blood sugar in people with type 2 diabetes. However, the drug can also be prescribed off-label for weight loss. (With off-label use, doctors prescribe a drug for a purpose other than what it’s approved for.)

Most health insurance providers do not cover medications used solely for weight loss. For example, Medicare and Medicaid generally do not cover weight-loss medications. Because of this, it’s important to check your specific plan benefits before starting Mounjaro treatment for weight loss.

Another drug called Zepbound contains the same active ingredient as Mounjaro and is FDA approved for weight loss. Some insurance providers may cover Zepbound for weight loss, although many don’t.

How much does Mounjaro cost without insurance?

If you’re interested in using Mounjaro for weight loss and your health plan doesn’t cover this use, a third-party savings coupon may help lower your out-of-pocket costs.

Do other GLP-1 drugs, like Ozempic or Wegovy, require step therapy?

Mounjaro is a type of drug called a dual GIP/GLP-1 receptor agonist. The step therapy requirements for other GLP-1 medications are often similar to those of Mounjaro.

To learn which drugs prescribed for type 2 diabetes have a step therapy requirement, check your specific health insurance benefits or talk with your doctor.

Takeaway

Some health insurance providers require step therapy for Mounjaro. This means you may have to try a drug from its preferred medications list before it will cover a non-preferred drug.

Before starting Mounjaro treatment, it’s important to check your coverage details with your insurance provider.