Does Kaiser cover Mounjaro?

In this article:

• Does Kaiser cover Mounjaro?
• Does Kaiser cover Mounjaro for weight loss?
• How much does Mounjaro cost without insurance?
• How much does Mounjaro cost with Kaiser?
• How to check whether your Kaiser plan covers Mounjaro
• How to save on Mounjaro

In this article

• Does Kaiser cover Mounjaro?
• Does Kaiser cover Mounjaro for weight loss?
• How much does Mounjaro cost without insurance?
• How much does Mounjaro cost with Kaiser?
• How to check whether your Kaiser plan covers Mounjaro
• How to save on Mounjaro

Mounjaro (tirzepatide) is a prescription drug developed by Eli Lilly. It is approved by the Food and Drug Administration (FDA) for treating Type 2 diabetes. As a dual glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) receptor agonist, it helps people manage their blood sugar levels. Because of its appetite-suppressing effects, it’s sometimes used for its weight-loss benefits. While it’s an effective drug, Mounjaro may be expensive, even with insurance. 

Does Kaiser cover Mounjaro?

Whether Kaiser Permanente covers Mounjaro depends on the specific plan and region, as well as the medical condition it’s being prescribed for. Kaiser may cover Mounjaro when it’s prescribed to treat Type 2 diabetes, but how it’s covered can differ based on your plan. In many cases, coverage for Mounjaro comes with various restrictions, depending on the plan:

• Prior authorization: Before getting coverage for Mounjaro, you need approval based on specific medical guidelines. This means your healthcare provider must provide details to show why you need this medication.
• Quantity limits: There’s a cap on how much Mounjaro you can get per prescription or over a certain period. If you need more than what’s allowed, you’ll have to get prior authorization to exceed these limits.
• Step therapy: To be covered, you might need to try a different drug first. If that doesn’t work, you can then get approval for Mounjaro, which may also require prior authorization.
• Maintenance medication guidelines: Once you start using Mounjaro regularly, you’ll need to get refills from a Kaiser pharmacy or their mail-order service. This rule is waived if you’re more than 30 miles away from a Kaiser pharmacy, and it only affects those on the Choice PPO plan.
• Coverage by KP pharmacy: Mounjaro is included under the HMO level of your POS plan when you fill your prescription at a KP pharmacy. It’s covered by a separate drug list, which you can check at kp.org/formulary.

Medicaid and Medicare coverage for Mounjaro can vary. Like other similar GLP-1 agonists, Mounjaro is approved to treat diabetes and is typically covered by most Medicaid plans for this purpose. However, Mounjaro isn’t listed on the 2025 Medicare Part D Formulary for Kaiser, so you may have to call your plan administrator for verification. It does cover Ozempic (semaglutide), though, another Type 2 diabetes medication that can help with weight loss.

RELATED: Mounjaro vs. Ozempic

Does Kaiser cover Mounjaro for weight loss?

Mounjaro is not generally covered for weight loss since it’s not FDA approved for weight loss. However, it might be covered by some plans and with prior authorization. For example, Mounjaro may be available under Kaiser Northwest’s prescription drug plan for weight loss, but only if you have coverage for weight loss drugs. If you’re not covered, you’ll have to pay the full out-of-pocket expenses.

Keep in mind that the active ingredient tirzepatide is available under a different brand name, Zepbound. Unlike Mounjaro, Zepbound is approved for weight loss and may be covered by some Kaiser plans. Zepbound and Mounjaro are virtually the same drug with similar dosages but different FDA-approved uses. 

How much does Mounjaro cost without insurance?

Without insurance, the cost of Mounjaro can vary depending on different factors, such as the pharmacy and location. The average retail price for a box of four 5 mg/0.5 mL prefilled pens is around $1,470. If you’re taking a higher dosage of Mounjaro, you might have higher overall costs than someone who takes a lower dose, since you’ll use pens more quickly. 

The cost of Mounjaro can also be affected by supply and demand, leading to periodic fluctuations in pricing. In addition, the price might vary based on whether the pharmacy is an independent local store or part of a larger chain.

How much does Mounjaro cost with Kaiser?

The exact cost of Mounjaro with Kaiser will depend on the specific plan. For example, some plans might list it as a Tier 2 drug, which means it’s a preferred brand-name medication. The California Grandfathered Point of Service (POS) for Large Groups Health Insurance Plans issued by Kaiser describes Mounjaro as a Tier 2 drug. 

Some plans might categorize it as a higher-tier or specialty medication, resulting in higher copayment or coinsurance amounts. In Washington, Kaiser’s individual and family plans list Mounjaro as a Tier 4 drug. Meanwhile, in Georgia, these plans classify Mounjaro as a Tier 5 drug, indicating an even higher tier.

How to check whether your Kaiser plan covers Mounjaro 

There are different ways you can check whether your Kaiser plan covers Mounjaro. You can consider the following when verifying your insurance coverage for Mounjaro: 

• Review your benefits plan document: Read through your evidence of coverage documents carefully to see if Mounjaro is listed as a covered medication. Pay attention to details about coverage levels and any specific requirements or restrictions. 
• Visit the Kaiser Permanente website: Log in to your account on the Kaiser Permanente website. Use the search function to find information on prescription drug coverage, specifically looking for Mounjaro. 
• Contact customer service: Call the customer service number provided on your insurance card. A representative can provide detailed information about whether Mounjaro is covered and any associated costs. 
• Consult your healthcare provider: They, as well as your pharmacist, can often provide insights into whether Mounjaro is typically covered under your plan and can help navigate any necessary steps for approval. 
• Check the formulary list: The drug formulary is a list of medications covered by your insurance plan. Check this list online or request a copy to see if Mounjaro is included. 
• Use the mobile app: If you have the Kaiser Permanente mobile app, use it to access your plan’s drug coverage details. Look for any information regarding Mounjaro under the prescriptions section. 

During Open Enrollment Periods, you can ask about changes to drug coverage. Your plan may also send an email out during this time to notify you about any changes. This is a good time to confirm if Mounjaro will be included in the next year’s benefits.

How to save on Mounjaro

If the out-of-pocket costs of Mounjaro are high with insurance or your plan doesn’t cover the drug, you have several options. You may be able to save on Mounjaro by using discount cards, seeking alternatives, and comparing prices across pharmacies. 

SingleCare offers Mounjaro coupons that can significantly reduce your cost. You can use the SingleCare app or website to compare prices at pharmacies near you and have your healthcare provider send your prescription to the pharmacy with the best coupon. When picking up your prescription, show your SingleCare prescription discount card or coupon to your pharmacist, and they’ll apply the savings. You can access your card via the SingleCare app for convenience as well. The process is straightforward and could save you up to 80% on brand-name and generic medications at more than 35,000 pharmacies across the country. For Mounjaro, you could pay as low as $872 instead of $1,470 for four 5 mg/0.5 mL prefilled pens. That’s a savings of close to $600.

If the cost of Mounjaro remains a limiting factor, you can consult a healthcare provider for potential Mounjaro alternatives that may be more affordable or covered by your plan. For example, your plan may cover similar medications like Ozempic (semaglutide), Wegovy (semaglutide), or Victoza (liraglutide). Always check with your health plan for specific coverage details and explore treatment options with a healthcare provider to discover the best options.