Do you have type 2 diabetes and you wish to treat it with Mounjaro but you are confused about the insurance that covers Mounjaro? Then keep reading as we explore Mounjaro and insurance in this article.
Managing type 2 diabetes can be a complex and costly endeavor, with many patients relying on a combination of medications, lifestyle changes, and ongoing medical care to keep their condition under control.
This is where Insurance comes in as it helps to reduce the cost spent on drugs which is quite expensive.
Understanding Mounjaro
One of the newest and most promising treatments for type 2 diabetes to emerge in recent years is Mounjaro (tripeptide).
It is a once-weekly injectable medication that has been shown to significantly improve blood sugar control and reduce the risk of cardiovascular events.
It belongs to a class of medications called GLP-1 receptor agonists, which work by helping the body produce more insulin and reduce the amount of glucose produced by the liver.
Mounjaro works by mimicking the effects of a hormone called glucagon-like peptide-1 (GLP-1) in the body.
GLP-1 helps regulate blood sugar levels by stimulating the release of insulin, slowing down
However, as with any prescription medication, the cost of Mounjaro can be a significant burden for many patients. Fortunately, many insurance plans are now covering Mounjaro, providing patients with access to this innovative treatment option.
Insurance Coverage for Mounjaro
Insurance coverage for Mounjaro may vary depending on the type of insurance plan you have.
However, many insurance plans, including Medicare, Medicaid, and private insurance, may cover Mounjaro to some extent.
Medicare Coverage for Mounjaro
Mounjaro is covered under Medicare Part D, which is the prescription drug benefit portion of Medicare.
Medicare Part D plans are offered by private insurance companies, and each plan has its formulary or list of covered medications.
Mounjaro is typically classified as a Tier 3 medication, which means it may have a higher copayment or coinsurance compared to Tier 1 or Tier 2 medications.
Mounjaro is covered under Medicare Part D, which is the prescription drug benefit portion of Medicare.
However, coverage and costs may vary depending on the specific Medicare plan you have such as:
Medicare Part D Plans: Most Medicare Part D plans cover Mounjaro, but the copayment or coinsurance amount may differ. You can check your plan’s formulary to see if Mounjaro is covered and what your out-of-pocket costs will be.
Medicare Advantage Plans: Some Medicare Advantage plans may also cover Mounjaro. These plans often have a network of providers and may require you to see a specialist within the network to get coverage.
Medicaid Coverage for Mounjaro
Medicaid coverage for Mounjaro varies by state. Some states may cover Mounjaro through their Medicaid program, while others may not.
Medicaid is a joint federal-state program that provides health coverage to low-income individuals and families.
While Medicaid is a federal program, each state administers its own Medicaid program, which means coverage for Mounjaro can vary significantly from state to state.
State-by-State Coverage: Check with your state’s Medicaid program to see if Mounjaro is covered. You can visit the Medicaid website or contact your state’s Medicaid office for more information.
Medicaid Copays and Coinsurance: If Mounjaro is covered by your state’s Medicaid program, you may be responsible for a copayment or coinsurance amount.
States with Coverage for Mounjaro
Below are some states with coverage for Mounjaro:
Alabama: Covered under the Alabama Medicaid Agency’s pharmacy benefit
Alaska: Covered under the Alaska Medicaid program
Arizona: Covered under the Arizona Health Care Cost Containment System (AHCCCS)
Arkansas: Covered under the Arkansas Medicaid program
California: Covered under the California Medi-Cal program
Colorado: Covered under the Colorado Medicaid program
Connecticut: Covered under the Connecticut Medicaid program
Delaware: Covered under the Delaware Medicaid program
Florida: Covered under the Florida Medicaid program
Georgia: Covered under the Georgia Medicaid program
Hawaii: Covered under the Hawaii Medicaid program
Idaho: Covered under the Idaho Medicaid program
Illinois: Covered under the Illinois Medicaid program
Indiana: Covered under the Indiana Medicaid program
Iowa: Covered under the Iowa Medicaid program
Kansas: Covered under the Kansas Medicaid program
Kentucky: Covered under the Kentucky Medicaid program
Louisiana: Covered under the Louisiana Medicaid program
Maine: Covered under the Maine Medicaid program
Maryland: Covered under the Maryland Medicaid program
Massachusetts: Covered under the Massachusetts Medicaid program
Michigan: Covered under the Michigan Medicaid program
Minnesota: Covered under the Minnesota Medicaid program
Mississippi: Covered under the Mississippi Medicaid program
Missouri: Covered under the Missouri Medicaid program
Montana: Covered under the Montana Medicaid program
Nebraska: Covered under the Nebraska Medicaid program
Nevada: Covered under the Nevada Medicaid program
New Hampshire: Covered under the New Hampshire Medicaid program
New Jersey: Covered under the New Jersey Medicaid program
New Mexico: Covered under the New Mexico Medicaid program
New York: Covered under the New York Medicaid program
North Carolina: Covered under the North Carolina Medicaid program
North Dakota: Covered under the North Dakota Medicaid program
Ohio: Covered under the Ohio Medicaid program
Oklahoma: Covered under the Oklahoma Medicaid program
Oregon: Covered under the Oregon Medicaid program
Pennsylvania: Covered under the Pennsylvania Medicaid program
Rhode Island: Covered under the Rhode Island Medicaid program
South Carolina: Covered under the South Carolina Medicaid program
South Dakota: Covered under the South Dakota Medicaid program
Tennessee: Covered under the Tennessee Medicaid program
Texas: Covered under the Texas Medicaid program
Utah: Covered under the Utah Medicaid program
Vermont: Covered under the Vermont Medicaid program
Virginia: Covered under the Virginia Medicaid program
Washington: Covered under the Washington Medicaid program
West Virginia: Covered under the West Virginia Medicaid program
Wisconsin: Covered under the Wisconsin Medicaid program
Wyoming: Covered under the Wyoming Medicaid program
States with Limited or No Coverage for Mounjaro
District of Columbia: Not covered under the DC Medicaid program
Michigan: Limited coverage under the Michigan Medicaid program (prior authorization required)
New York: Limited coverage under the New York Medicaid program (prior authorization required)
Ohio: Limited coverage under the Ohio Medicaid program (prior authorization required)
How to Check Medicaid Coverage for Mounjaro in Your State
To check Medicaid coverage for Mounjaro in your state, follow these steps:
- Visit your state’s Medicaid website or contact your state’s Medicaid program directly.
- Search for the Medicaid formulary or list of covered medications.
- Look for Mounjaro (tripeptide) or its generic name.
- Review the coverage information, including any prior authorization requirements or limitations.
Private Insurance Plans that Cover Mounjaro
While insurance coverage for Mounjaro can vary, many private insurance plans cover this medication.
Here are some private insurance plans that may cover Mounjaro:
UnitedHealthcare
UnitedHealthcare offers coverage for Mounjaro under many of its plans, including employer-sponsored and individual plans.
Copays and coinsurance amounts may vary depending on the specific plan and tiered coverage.
Anthem
Anthem, Inc. covers Mounjaro under many of its plans, including employer-sponsored and individual plans.
Coverage and costs may vary depending on the specific plan and state.
Aetna
Aetna covers Mounjaro under many of its plans, including employer-sponsored and individual plans.
Copays and coinsurance amounts may vary depending on the specific plan and tiered coverage.
Cigna
Cigna covers Mounjaro under many of its plans, including employer-sponsored and individual plans.
Coverage and costs may vary depending on the specific plan and state.
Humana
Humana covers Mounjaro under many of its plans, including employer-sponsored and individual plans.
Copays and coinsurance amounts may vary depending on the specific plan and tiered coverage.
Blue Cross Blue Shield (BCBS)
BCBS plans vary by state and region, but many BCBS plans cover Mounjaro.
Coverage and costs may vary depending on the specific plan and state.
Kaiser Permanente
Kaiser Permanente covers Mounjaro under many of its plans, including employer-sponsored and individual plans.
Copays and coinsurance amounts may vary depending on the specific plan and tiered coverage.
Centene
Centene covers Mounjaro under many of its plans, including employer-sponsored and individual plans.
Coverage and costs may vary depending on the specific plan and state.
Molina Healthcare
Molina Healthcare covers Mounjaro under many of its plans, including employer-sponsored and individual plans.
Copays and coinsurance amounts may vary depending on the specific plan and tiered coverage.
Ambetter
Ambetter covers Mounjaro under many of its plans, including employer-sponsored and individual plans.
The out-of-pocket cost of Mounjaro for uninsured individuals
If you are uninsured or your insurance plan does not cover Mounjaro, you may be responsible for the full cost of the medication out-of-pocket.
The out-of-pocket cost of Mounjaro can vary depending on several factors, including the dosage, frequency, and duration of treatment.
Average Wholesale Price (AWP) of Mounjaro
The average wholesale price (AWP) of Mounjaro is around $1,000 per month for a 30-day supply. This price is subject to change and may vary depending on the pharmacy, location, and other factors.
Estimated Out-of-pocket Cost of Mounjaro
Based on the AWP, the estimated out-of-pocket cost of Mounjaro for uninsured individuals can be:
$1,000 per month for a 30-day supply
$3,000 per quarter (every 3 months) for a 90-day supply
$12,000 per year for a 12-month supply
Discounts and Financial Assistance Programs For Mounjaro
There may be discounts and financial assistance programs available to help reduce the out-of-pocket cost of Mounjaro for uninsured individuals.
These programs may include:
Manufacturer discounts: Eli Lilly, the manufacturer of Mounjaro, may offer discounts or patient assistance programs to eligible patients.
Pharmacy discounts: Some pharmacies may offer discounts or price matching for Mounjaro.
Coupon programs: Online coupon programs or discount cards may be available to reduce the cost of Mounjaro.
Non-profit organizations: Some non-profit organizations, such as the Patient Access Network Foundation (PAN), may offer financial assistance to eligible patients.
Tips for Getting Approved for Insurance Coverage for Mounjaro
Getting approved for insurance coverage for Mounjaro can be a challenging process, but several tips can increase your chances of success.
Here are some tips to help you get approved for insurance coverage for Mounjaro:
Check Your Policy: Review your insurance policy to ensure that Mounjaro is covered. Check the formulary, or list of covered medications, to see if Mounjaro is included.
Meet the Criteria: Ensure that you meet the insurance company’s criteria for coverage. This may include having a diagnosis of type 2 diabetes, trying other medications, and meeting certain medical criteria.
Get a Prior Authorization: Obtain prior authorization from your insurance company before filling your prescription. This can help ensure that your claim is approved.
Provide Medical Necessity: Provide documentation from your healthcare provider that explains why Mounjaro is medically necessary for your treatment.
Appeal a Denial: If your claim is denied, appeal the decision. Work with your healthcare provider to gather supporting documentation and submit an appeal.
Consider a Patient Assistance Program: If you’re uninsured or underinsured, consider applying for a patient assistance program (PAP) offered by the manufacturer, Eli Lilly.
Work with Your Healthcare Provider: Collaborate with your healthcare provider to ensure that all necessary documentation is submitted and that your claim is processed correctly.
Be Prepared to Negotiate: Be prepared to negotiate with your insurance company if your claim is denied. Provide additional information and supporting documentation to help justify coverage.
Check for State-Specific Programs: Check if your state has programs that can help with medication costs, such as Medicaid or state-specific patient assistance programs.
Seek Professional Help: If you’re having trouble getting approved for insurance coverage, consider seeking the help of a patient advocate or a healthcare professional who specializes in insurance coverage.
What Affects the Price of Mounjaro?
The price of Mounjaro (tripeptide) can vary depending on several factors. Here are some of the key factors that can affect the price of Mounjaro:
Location
The price of Mounjaro can vary depending on the location where you purchase it. Prices may be higher or lower in different cities, states, or countries.
Pharmacy
The price of Mounjaro can vary depending on the pharmacy where you purchase it. Different pharmacies may charge different prices for the same medication.
Insurance Coverage
The price of Mounjaro can vary depending on your insurance coverage. If you have insurance, your copay or coinsurance may be lower than the cash price.
Dosage and Quantity
The price of Mounjaro can vary depending on the dosage and quantity you need. Higher dosages or larger quantities may cost more.
Manufacturer Discounts
Eli Lilly, the manufacturer of Mounjaro, may offer discounts or patient assistance programs that can reduce the price of the medication.
Wholesale Prices
The wholesale price of Mounjaro can affect the price you pay. Wholesale prices may vary depending on the supplier and the quantity purchased.
Middlemen and Markups
Middlemen, such as wholesalers and distributors, may mark up the price of Mounjaro before it reaches the pharmacy. These markups can increase the final price you pay.
Government Pricing Regulations
Government pricing regulations, such as Medicaid rebates and Medicare pricing rules, can affect the price of Mounjaro.
Competition
The price of Mounjaro can be affected by competition from other medications in the same class. If there are other similar medications available, the price of Mounjaro may be lower to remain competitive.
Research and Development Costs
The cost of research and development for Mounjaro can affect its price. The manufacturer may need to recoup these costs through higher prices.
Marketing and Advertising
The cost of marketing and advertising Mounjaro can affect its price. These costs may be passed on to consumers through higher prices.
Distribution and Logistics
The cost of distributing and transporting Mounjaro can affect its price. These costs may be higher in certain regions or countries.
FAQs
What is the Average Cost of Mounjaro, and how does it vary Based on the Dosage and Frequency of Treatment?
The average cost of Mounjaro can vary depending on the dosage and frequency of treatment. According to the manufacturer’s website, the list price of Mounjaro is around $1,000 per month for a 30-day supply. However, the actual cost may be higher or lower depending on the patient’s insurance coverage, copays, and coinsurance. The dosage and frequency of treatment can also impact the cost, as patients who require higher doses or more frequent injections may need to pay more.
How do Insurance Coverage and Copays Affect the Price of Mounjaro, and What are Some Common Insurance Coverage Scenarios?
Insurance coverage and copays can significantly impact the price of Mounjaro. Patients with insurance coverage may have a lower out-of-pocket cost due to copays and coinsurance. However, the specific insurance coverage and copays can vary widely depending on the patient’s insurance plan and provider. Some common insurance coverage scenarios include:
Patients with Medicare Part D coverage may have a copay of around 40−40−60 per month.
Patients with private insurance coverage may have a copay of around 20−20−50 per month.
Patients without insurance coverage may need to pay the full list price of around $1,000 per month.
Are there any Discounts, Coupons, or Patient Assistance Programs Available to help Reduce the cost of Mounjaro, and how can Patients Access These Resources?
Yes, there are several discounts, coupons, and patient assistance programs available to help reduce the cost of Mounjaro. Patients can access these resources through the manufacturer’s website, patient advocacy groups, or non-profit organizations. Some examples include:
The Mounjaro Savings Card can provide a discount of up to $150 per month.
The Lilly Cares patient assistance program, can provide free or discounted Mounjaro to eligible patients.
The Patient Access Network Foundation (PAN), can provide financial assistance to eligible patients.
