{"id":627689,"date":"2024-04-05T15:15:39","date_gmt":"2024-04-05T19:15:39","guid":{"rendered":"https:\/\/www.singlecare.com\/blog\/?p=627689"},"modified":"2025-10-22T19:27:50","modified_gmt":"2025-10-22T23:27:50","slug":"does-bcbs-cover-mounjaro","status":"publish","type":"post","link":"https:\/\/www.singlecare.com\/blog\/does-bcbs-cover-mounjaro\/","title":{"rendered":"Does BCBS cover Mounjaro? It depends"},"content":{"rendered":"

Nationwide diabetes expenses topped $418 billion in 2022\u2014and most of that money went to direct treatment, including medications like <\/span>Mounjaro (tirzepatide)<\/span><\/a>, according to the <\/span>American Diabetes Association<\/span><\/a>. This injectable prescription drug mimics the hormones GIP and GLP-1, which stimulate insulin production, lowering blood sugar in individuals with Type 2 diabetes. Many patients look to health insurance or Medicare for help with Mounjaro\u2019s out-of-pocket price. And when it\u2019s prescribed for diabetes, not weight loss, insurance often covers the cost. However, it depends on the provider and plan.\u00a0<\/span><\/p>\n

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Does BCBS cover Mounjaro?<\/span><\/h2>\n

It\u2019s difficult to make sweeping generalizations about insurance coverage since it\u2019s highly complicated, and every health plan is different\u2014even plans from the same provider. Additionally, insurance plans can change their rules anytime. Plus, Blue Cross Blue Shield (BCBS) is actually a system made up of <\/span>33 local, independent licensees<\/span><\/a> of the Blue Cross Blue Shield Association, and each of those companies has its own policies.<\/span><\/p>\n

Therefore, some BCBS members receive coverage for Mounjaro, while others might not. The only way to know for sure is to check the plan\u2019s formulary, which is a list of drugs it covers. There are a few factors that might influence coverage, including the reason for taking it, whether you need prior authorization, and which tier the drug falls into.<\/span><\/p>\n

Reason for taking it<\/span><\/h3>\n

Doctors use Mounjaro to treat Type 2 diabetes or obesity, but insurance plans typically only cover it for diabetes, not as a weight loss medication.\u00a0<\/span><\/p>\n

However, Eli Lilly produces another tirzepatide drug called <\/span>Zepbound<\/span><\/a>. According to Alex Foxman, MD, a physician and medical director for <\/span>Achieve Health and Weight Loss<\/span><\/a>, \u201cMounjaro is <\/span>FDA approved for Type 2 diabetes mellitus<\/span><\/a>, while Zepbound is FDA approved for obesity, but they are exactly the same medication with exactly the same dosing schedule.\u201d Blue Cross Blue Shield may cover Zepbound for obesity treatment, but again, it all depends on the plan.\u00a0<\/span><\/p>\n

Prior authorization<\/span><\/h3>\n

Sometimes, a BCBS plan will cover Mounjaro, but only if the patient meets certain <\/span>prior authorization (or pre-authorization) requirements<\/span><\/a>. This can include a \u201cdocumented diagnosis for Type 2 diabetes mellitus and a medical test confirmation, and the patient must be older than 18 years old,\u201d says <\/span>Sarah Bonza, MD<\/span><\/a>, founder of <\/span>Bonza Health<\/span><\/a>. Some patients may even need to have their medical provider submit a prior authorization every year.\u00a0<\/span><\/p>\n

In her personal experience, Dr. Bonza says prior authorization has also meant her patients must have \u201cpersistently elevated A1C despite oral therapy.\u201d On top of that, she says, \u201cSometimes it helps to have a comorbidity, particularly heart failure.\u201d<\/span><\/p>\n

RELATED:<\/b> BCBS Wegovy prior authorization criteria<\/span><\/a><\/p>\n

Formulary tier<\/span><\/h3>\n

Plan formularies typically designate drugs as either preferred or non-preferred. They also organize these drugs into tiers\u2014generics and preferred brands on the lower tiers and nonpreferred brands on the higher ones. The insurance company might cover certain brands on each tier, but drugs on their higher tiers typically have higher out-of-pocket costs, including copayments and coinsurance. Or, the company may request that the patient try a preferred option before it covers a nonpreferred one.\u00a0\u00a0<\/span><\/p>\n

For example, Dr. Bonza says, \u201cOhio has Anthem Blue Cross Shield, and Mounjaro is Tier 2 and requires prior authorization.\u201d Just remember that each BCBS company and plan has its own tier system, so while some might also put Mounjaro in tier 2, others might put it higher.\u00a0<\/span><\/p>\n

How much does Mounjaro cost?<\/span><\/h2>\n

Like many prescription drugs, without insurance coverage, Mounjaro isn\u2019t cheap. Prices vary by pharmacy and location, but the <\/span>average cos<\/span><\/a>t is $1,474 for a 30-day supply, which comprises four single-dose pens. That means a full year\u2019s worth of Mounjaro could cost over $17,000 without insurance or assistance.<\/span><\/p>\n

Copays<\/span><\/a> are one of the main out-of-pocket costs for prescription drugs, and many BCBS plans have them. According to <\/span>KFF\u2019s 2022 employer health benefits survey<\/span><\/a>, the average copay across insurance companies is $11 for first-tier drugs, $37 for second-tier drugs, $67 for third-tier drugs, and $116 for fourth-tier drugs. Many plans put Mounjaro prescribed for diabetes in the second or third tier, although some put it higher.\u00a0<\/span><\/p>\n

How to check whether your BCBS plan covers Mounjaro<\/span><\/h2>\n

Mounjaro coverage depends on your specific insurance plan. Everything you need is in the plan\u2019s formulary, a list that shows how the plan covers various generic and brand-name medications and which tier they\u2019re on.\u00a0<\/span><\/p>\n

Because BCBS has so many independent licensees, it also has numerous formularies, each with its own tier system and requirements. If you log in to your plan online, you can access your formulary under \u201cResources\u201d or \u201cBenefits.\u201d Once you have access to the formulary for your plan, scroll down to find Mounjaro, and you will know if the medication is preferred and which tier it is on.\u00a0<\/span><\/p>\n

Simply calling the company and asking is also an option. The representative will likely ask for information on your insurance card, such as your account and group numbers. Have that info handy when you call.\u00a0<\/span><\/p>\n

How to save on Mounjaro<\/span><\/h2>\n

No matter where it falls on the formulary, there are some effective <\/span>ways to reduce Mounjaro\u2019s cost<\/span><\/a>. Here are a few of the most common.\u00a0<\/span><\/p>\n