How to Get Mounjaro (tirzepatide) Covered by Insurance

Starting around early March 2023, I started noticing that many of my patients who have been getting Mounjaro for $25 a month are now having to pay full price. Over the past few months, insurance companies have been quietly changing their rules, and have started denying prescriptions for Mounjaro for patients who do not have diabetes. Changes in the Mounjaro saving card rules have made the process even more difficult. This has become a major challenge, especially for those who have lost so much weight and have improved their health with Mounjaro.

Many of my patients who take Mounjaro for weight loss do not have diabetes. Mounjaro is currently approved to treat diabetes, but the research shows incredible results for weight loss in patients who do not have diabetes. Over the past year, since Mounjaro came out, my patients have described similar experiences with Mounjaro. The improvements they describe are more than what is listed in the label. In addition to weight loss, decreased appetite, filling up more easily, decrease in cravings, there is an overall decrease in the desire for food. People are starting to call it “food noise.” My patients tell me things like I finally feel like a normal person around food. They say they don't constantly think about food all the time. They say food is no longer a major influence in their life decisions. Amazingly I hear other improvements including a decrease in the desire to drink alcoholic beverages. This has become a common improvement I have heard numerous times from my patients. They tell me they have fewer alcohol cravings and many patients have told me they have stopped drinking altogether.

A uniform improvement that almost all of my patients tell me is that Mounjaro has resulted in a major improvement in their quality of life. Patients who have struggled with depression or anxiety for many years tell me that they no longer struggle with mental health issues. Patients with chronic pain tell me the pain has gone away. People who have had chronic fatigue now have limitless energy. My observations are not scientific and do not mean that anybody else will have these improvements, however I find it quite remarkable that so many people have benefited in so many ways from Mounjaro.

This is why it has been so frustrating that many people who have been paying $25 a month for Mounjaro now must pay full price. This is why I have appealed denials for Mounjaro. The key is to follow all the policies and procedures of the specific insurance plan to ensure that the prescription for Mounjaro remains affordable. The following steps have been helpful in ensuring that Mounjaro denials are overturned.

1. Careful medical record documentation of weight loss, health problems and improvements.
   
   
2. File Prior Authorization using the specific form for each insurance company.
   
   
3. Follow up denials with 1^st level appeal. Include a detailed letter documenting the impact of discontinuing Mounjaro specific to all health problems and improvements.
   
   
4. Include at least 2 current peer-reviewed journal articles supporting the use of Mounjaro for the specific patient situation.
   
   
5. File 2^nd level appeal for appeal denials, reassert important reasons why Mounjaro is medically necessary and the harm it could cause to discontinue Mounjaro including weight regain and return of health issues.
   
   
6. File 3^rd level appeal for second level appeal denials. Submit hard copies of necessary documentation. Send certified mail. Follow up on receipt by insurance company. Insist on response date.
   
   
7. Schedule peer-to-peer call with insurance company medical director. Insist that the medical director be either an endocrinologist or obesity medicine specialist.
   
   
8. Reaffirm the patient improvements, medical necessity for Mounjaro and peer-reviewed literature with the medical director. Help the medical director understand that Mounjaro is medically necessary and why. Use specific examples. Appeal to the humanistic side of the medical director.

I have found that by following these steps, patients who do not have diabetes can get Mounjaro at an affordable price, usually less than $100 per month. This is my personal experience and may not be the same everywhere or for everyone. This process takes a lot of time, and hard work. It is not a simple process. But the process does work in my experience.

For those that can’t get Mounjaro covered, there are other options for GLP-1 medications, including semaglutide (Wegovy, Ozempic, Rybelsus), dulaglutide (Trulicity), liraglutide (Saxenda, Victoza) and other medications for weight loss. But the most important thing to remember is that no matter what, you must do your part. Your diet, exercise and lifestyle are the key critical components to being healthy and never lose sight of that.

Author

Scott Isaacs, MD Endocrinologist and Weight Loss Specialist