Is Mounjaro covered by Medicaid?

Mounjaro (tirzepatide) is an injectable medication prescribed for Type 2 diabetes mellitus, which some doctors may prescribe off-label for weight loss. At first glance, Mounjaro might look pretty pricey, but its out-of-pocket costs can vary drastically based on insurance coverage, discounts, pharmacy location, and more. In limited instances, Medicaid programs may cover Mounjaro for weight loss, but it depends on the state, and most only cover it for diabetes treatment. Here’s all the important information about Mounjaro’s Medicaid coverage. 

How much does Mounjaro cost?

The list price for brand-name products can be steep, and Mounjaro is no exception. Without help from a health insurance plan, Medicare Part D, or Medicaid, the drug’s list price is $1,069.08 per 30-day supply (a pack of four pens). 

That price could depend on where you get your Mounjaro prescription filled, though. A study published in 2022 found “significant price variation in community pharmacies,” and a Consumer Reports survey showed prices can vary by hundreds of dollars between pharmacies—even ones in the same town.

Does Medicaid cover Mounjaro?

Medicaid is a federal- and state-funded program that provides free or steeply discounted health insurance, often including coverage for prescription drugs. Over 80 million Americans received Medicaid assistance in 2023, and it sometimes covers Mounjaro for diabetes treatment. In 2022—the year Mounjaro hit the market—Medicaid dispersed nearly $30 million to help beneficiaries pay for it, according to KFF data. 

Yet that’s not necessarily a guarantee. Medicaid might cover it in some circumstances but not others. For example, Sarah Bonza, MD, founder of Bonza Health, says, “I just had a 49-year-old patient with a new diagnosis of diabetes and atrial fibrillation. I tried to prescribe Mounjaro, which helps with heart failure and diabetes, but I couldn’t get it covered.” 

That said, some people might receive assistance, but usually only if it’s prescribed for diabetes, not weight management. Legislation passed in 2003 prohibits Medicare from covering drugs prescribed specifically for weight loss, and while Medicaid has more flexibility here, not every state will cover them. Mounjaro’s only on-label use is for diabetes, so Medicaid likely won’t cover it for obesity. However, some states may cover it in extremely limited situations, and many are considering expanding coverage.

Eli Lilly markets tirzepatide under the brand name Zepbound as a weight-loss medication. Alex Foxman, MD, physician and medical director for Achieve Health and Weight Loss, says, “They are exactly the same medication with exactly the same dosing schedule.” KFF data indicates that Medicaid spent around $39 million in 2022 covering Wegovy, a similar drug that’s approved specifically for obesity treatment. Regardless, Medicaid beneficiaries should check with their state to see whether their plan might cover Mounjaro or Zepbound. 

Costs of Mounjaro under Medicaid

All 50 states include some prescription drug coverage in their Medicaid plans. The question is how much coverage. Each state gets to dictate its own insurance premiums and out-of-pocket requirements, including deductibles, copays, and coinsurance. This is called cost sharing.

Medicaid allows states to decide which medicines on their drug lists are “preferred” or “non-preferred,” and states can use these out-of-pocket requirements to push patients toward their preferred—typically less expensive—medications. People with incomes above 150% of the federal poverty level could pay up to 20% of the drug’s cost in copays, while people at or below 150% will only pay nominal amounts.

Mounjaro will likely be cheaper in states that consider it a preferred drug than in states where it’s nonpreferred. Check with your state’s Department of Health to inquire about Medicaid cost-sharing requirements.

Factors influencing Medicaid coverage of Mounjaro 

The purpose of the prescription, or “indication,” is the main factor determining whether Medicaid will cover Mounjaro. Some people received coverage for Type 2 diabetes, but not many for weight loss. 

And even if a state covers Mounjaro, some may have prior authorization requirements. According to Dr. Bonza, these requirements might include a documented diagnosis of Type 2 diabetes mellitus and confirmation with a medical test. She also says some patients must get prior authorization every year. In certain cases, the state may request that a patient try certain preferred medications before it approves Mounjaro. This can happen if it classifies Mounjaro as a nonpreferred option. 

Right now, it appears as though Medicaid might prefer more established medications. “I am seeing Ozempic (semaglutide) approval at a higher rate than Mounjaro, even though the cost of Ozempic is higher,” Dr. Foxman says. “I believe that as pharmacy benefit managers (PBMs) and insurance companies better understand the power of these medications and the likely long-term overall patient cost reduction due to better outcomes, these medications will be better covered.” 

It’s important to remember that these are relatively new drugs, and the landscape is constantly changing. Continue checking with your insurance provider to verify whether coverage has changed. 

Ways to get discounts on Mounjaro

Using Medicaid or other insurance coverage is one of the best ways to reduce the cost of Mounjaro, but for people who don’t have insurance or whose plans might not prefer it, there are other ways to discount its cost. Here are a few:

• Enroll in the Mounjaro Savings Card Program. People who have private health insurance instead of Medicare or Medicaid might be eligible for this card, which could lower their out-of-pocket costs to as low as $25 per month. 
• Get a SingleCare prescription discount card. SingleCare discounts can knock hundreds off the cash price of Mounjaro—and it’s free to sign up. Members can use SingleCare if they’re on Medicaid, but they can’t stack the discounts on top of Medicaid coverage. 
• Look into state-funded assistance. Most states have a pharmaceutical assistance program for Medicare beneficiaries, low-income individuals, and other groups.
• Go to a trustworthy healthcare provider. Part of paying less is simply avoiding price gouging. People who purchase Mounjaro treatment from a wellness clinic or med spa with no doctors on-site might risk paying a lot more. 
• Ask your healthcare provider. Doctors are familiar with patient assistance programs, discount opportunities, and other ways to save money, so don’t be afraid to ask.
• Look into compounded options (but be careful). Due to tirzepatide being placed on the Food and Drug Administration (FDA) shortage list, “compounding pharmacies are able to replicate it at up to 70% discounted cost,” Dr. Foxman says. “But there must be caution, as the quality control and ingredients used may not be well overseen and may lead to poor outcomes. In addition, once the medications are removed from the FDA shortage list, it will be illegal for compounding pharmacies to replicate these medications due to patent laws.”

Be wary of any sources who claim to be selling generic or steeply discounted Mounjaro. The Food and Drug Administration has discovered counterfeit Ozempic pens and is investigating counterfeit Mounjaro sales as well. When looking for ways to save on Mounjaro, be sure to get it from a licensed, reputable doctor.