Mounjaro Step Therapy: What’s the Process to Get Coverage?
Step therapy is a process your health insurance provider may require before it will cover certain drugs. Many insurance providers require step therapy for Mounjaro (a drug prescribed for type 2 diabetes).
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 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.
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 other reason.
- Your doctor determines (for medical reasons) that you should try a non-preferred alternative.
Does Mounjaro have a step therapy requirement?
Many health insurance providers have a step therapy requirement for Mounjaro.
For example, some plans may require you to try a generic type 2 diabetes drug, such as metformin, before it will cover Mounjaro (which is a brand-name drug). A generic contains an exact copy of the active drug in a brand-name medication. A generic is considered just as safe and effective as the original drug but tends to cost less.
Or 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. (To learn more, see the section below.)
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, Medicaid and Medicare 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, check out these Optum Perks coupons. (Note: Optum Perks coupons cannot be used with any insurance copays or benefits.)
Do other GLP-1 drugs, like Ozempic or Wegovy, require step therapy?
Mounjaro is a type of drug called a 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.
What is Mounjaro Step Therapy?
Mounjaro Step Therapy is a process used by insurance providers to determine if they will cover the cost of a medication. It requires patients to try and fail less expensive or alternative treatments before the insurance company will approve more costly options like Mounjaro.
Why is Step Therapy Required for Mounjaro?
Step therapy is often required to control healthcare costs by ensuring patients first use medications that are proven effective and more cost-efficient. This approach helps insurers manage spending while still providing necessary drugs.
How Does the Step Therapy Process Work for Mounjaro?
The step therapy process for Mounjaro involves a few steps:
- Initial Medication Trial**: Patients must first use one or more specified alternative medications.
- Documentation of Failure or Intolerance**: If these alternatives are ineffective or cause side effects, the healthcare provider documents these results.
- Submission for Approval**: The healthcare provider submits a formal request for Mounjaro coverage, including evidence of the trial’s failure or intolerance.
- Review and Decision**: The insurance company reviews the submission and makes a coverage decision.
What Documentation is Needed for Mounjaro Step Therapy?
Patients need documentation from their healthcare provider that demonstrates the failure or intolerance of lower-step medications. This might include medical records, prescription histories, and any other relevant health details.
How Long Does the Mounjaro Step Therapy Process Take?
The duration can vary depending on the insurance provider and the completeness of the submitted documentation. Typically, once all required information is submitted, a decision may take from several days to a few weeks.
Can Mounjaro Step Therapy Be Overturned?
Yes, if an initial request is denied, patients can appeal the decision. This involves submitting additional information or documentation supporting why Mounjaro is necessary for their treatment.
Who Can Assist With the Mounjaro Step Therapy Process?
Patients are encouraged to work closely with their healthcare providers, who can offer necessary documentation and guidance throughout the step therapy procedure. Some insurance companies also provide customer support to assist with the process.
What Happens if Step Therapy Fails With Mounjaro?
If step therapy fails to receive approval for Mounjaro coverage, patients may need to explore alternative treatments, consider paying out-of-pocket, or approach patient assistance programs offered by the drug manufacturer.
Are There Exceptions to Mounjaro Step Therapy?
In certain situations, such as medical necessity or specific patient circumstances, exceptions to the step therapy requirement may be granted. This requires additional documentation and justification from the patient’s healthcare provider.
Summary
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.
