Does Express Scripts Cover Mounjaro for Weight Loss?
Mounjaro, a popular medication, has sparked interest for its potential in weight loss. Many people with Express Scripts insurance want to know if it’s covered for this purpose.
This article explores whether Express Scripts covers Mounjaro for weight loss, the factors involved, and how to navigate the process.
What Is Mounjaro?
Mounjaro, known as tirzepatide, is a prescription drug. It’s primarily FDA-approved for managing type 2 diabetes in adults. The medication mimics hormones to regulate blood sugar and appetite. It’s given as a weekly injection.
Some doctors prescribe Mounjaro off-label for weight loss. Its ability to reduce appetite has shown promising results. However, off-label use often affects insurance coverage.
Understanding Express Scripts Coverage
Express Scripts is a pharmacy benefit manager (PBM). It handles prescription drug benefits for millions of members. Coverage depends on your specific health plan’s formulary, a list of approved medications.
Formularies categorize drugs into tiers. These tiers determine your out-of-pocket costs. Express Scripts works with employers, unions, and insurers to set these rules.
Does Express Scripts Cover Mounjaro for Weight Loss?
Express Scripts typically covers Mounjaro for type 2 diabetes. Coverage for weight loss, however, is less common. Most plans require Mounjaro to be prescribed for its FDA-approved use, not off-label purposes like weight loss.
Some individual plans may allow coverage for weight loss. This often requires meeting specific criteria, such as a high BMI or related health conditions. Prior authorization is usually needed.
Factors Affecting Coverage
Several factors determine whether Express Scripts covers Mounjaro for weight loss. These include your plan’s rules, medical diagnosis, and documentation. Here’s what matters:
- Plan Formulary: Check if Mounjaro is listed for weight loss in your plan’s drug list.
- Medical Criteria: Plans may require a BMI of 30+ or 27+ with conditions like hypertension.
- Prior Authorization: Your doctor must submit proof of medical necessity.
- Employer Rules: Some employers exclude weight loss drugs entirely.
If these conditions aren’t met, coverage may be denied. Always confirm with Express Scripts or your plan administrator.
How to Verify Mounjaro Coverage
Start by checking your plan’s formulary. Log into your Express Scripts account or visit their website. The formulary lists covered drugs and their tiers.
Call Express Scripts Customer Service at 1-800-467-2006 for clarification. Your doctor can also contact them to confirm coverage. They may need to submit a prior authorization request.
Ask about step therapy requirements. Some plans mandate trying lower-tier drugs first. This information helps avoid unexpected denials.
Costs of Mounjaro with Express Scripts
If covered, Mounjaro’s cost depends on its formulary tier. It’s often placed in a higher tier, meaning higher copays. Copays can range from $50 to $100 or more, based on your plan.
Without coverage, Mounjaro costs over $1,400 for a 30-day supply. Express Scripts’ mail-order pharmacy may offer savings for covered prescriptions. Check your plan’s details for exact costs.
Eli Lilly, Mounjaro’s manufacturer, offers a savings card. It can reduce costs to as low as $25 for eligible patients. However, federal plans may not qualify.
Table: Mounjaro Coverage Scenarios with Express Scripts (2025)
| Purpose | Coverage Likelihood | Typical Requirements | Estimated Copay |
|---|---|---|---|
| Type 2 Diabetes | High | Prior authorization, diagnosis | $50–$100 |
| Weight Loss | Low to Moderate | BMI 30+, prior authorization | $50–$150 |
| Off-Label (Other) | Very Low | Formulary exception | Varies |
Note: Coverage and costs vary by plan. Confirm with Express Scripts for accuracy.
What If Coverage Is Denied?
If Express Scripts denies Mounjaro for weight loss, you have options. Your doctor can request a formulary exception. This requires evidence that Mounjaro is medically necessary.
You can also appeal the denial. Express Scripts provides an appeal process, detailed in your denial letter. Submitting additional medical records may help.
Explore alternative medications. Drugs like Wegovy or Saxenda may be covered for weight loss. Discuss options with your healthcare provider.
Mounjaro vs. Zepbound: Coverage Differences
Mounjaro and Zepbound are both tirzepatide, made by Eli Lilly. Mounjaro is approved for diabetes, while Zepbound is FDA-approved for weight loss. This distinction affects coverage.
Express Scripts is more likely to cover Zepbound for weight loss than Mounjaro. Some plans added Zepbound to their formularies in 2024. Check if your plan includes it.
Prior authorization is required for both drugs. Confirm which is covered to avoid surprises. Your doctor can help clarify the best option.
Express Scripts’ Weight Management Program
Express Scripts offers a weight management program. It may include access to weight loss medications for eligible members. However, not all plans participate in this program.
The program often requires lifestyle changes, like diet or exercise plans. It may also involve step therapy, starting with non-injectable drugs. Contact Express Scripts to see if you qualify.
If Mounjaro is included, coverage still depends on your plan. Verify eligibility to understand your benefits. This program could lower costs for approved members.
Tips for Navigating Coverage
Managing prescription coverage can be complex. These tips can help:
- Check Your Formulary: Review the latest drug list on Express Scripts’ website.
- Involve Your Doctor: Ensure they submit all required paperwork.
- Use Network Pharmacies: Fill prescriptions at in-network or mail-order pharmacies.
- Monitor Appeals: Follow up on denials or exceptions promptly.
Staying proactive reduces delays and costs. Keep records of all communications for reference.
Recent Updates for 2025
In 2025, Express Scripts updated some formularies. Coverage for GLP-1 drugs, like Wegovy and Zepbound, expanded in certain plans. Mounjaro’s coverage for weight loss remains limited, though.
Some plans now cover weight loss drugs for members with specific conditions. BMI requirements and prior authorization are still common. Check your 2025 formulary for changes.
Express Scripts continues to prioritize FDA-approved uses. Off-label coverage for Mounjaro is less likely without strong justification. Contact them for the latest details.
Prior Authorization Process
Prior authorization is often required for Mounjaro. Your doctor submits medical records to Express Scripts. These show why Mounjaro is needed for your condition.
The process takes about 48 hours. If approved, you’ll pay the standard copay. If denied, Express Scripts will explain why and suggest alternatives.
Ensure all documentation is complete. Missing information can delay approval. Your doctor can call 1-800-753-2851 for assistance.
Patient Assistance Options
If Mounjaro isn’t covered, consider assistance programs. Eli Lilly’s savings card can lower costs for eligible patients. It’s available for commercial insurance holders, but restrictions apply.
Other programs, like RxAssist, offer resources for medication costs. These can help if your plan excludes weight loss drugs. Check eligibility on the manufacturer’s website.
Some pharmacies offer discounts for cash payments. Compare prices at in-network pharmacies to find the best deal. These options can make Mounjaro more affordable.
Why Coverage Varies
Express Scripts serves diverse health plans. Each plan sets its own formulary and rules. Employers or insurers decide whether to cover weight loss drugs.
Some plans exclude them to control costs. Others include them for members with obesity-related conditions. Your plan’s priorities shape Mounjaro’s coverage.
Regional differences also exist. Formularies may vary slightly by state or employer. Always verify your specific plan’s details.
Summary
Express Scripts typically covers Mounjaro for type 2 diabetes, but coverage for weight loss is less common. It depends on your plan’s formulary, medical criteria, and prior authorization. Some plans may cover Zepbound, Mounjaro’s weight loss counterpart, instead. Check your formulary, work with your doctor, and explore assistance programs to manage costs. Staying informed helps you access Mounjaro or alternatives affordably.
FAQ
Does Express Scripts cover Mounjaro for weight loss?
Coverage for weight loss is limited and varies by plan. Mounjaro is more likely covered for type 2 diabetes. Check your formulary and confirm with Express Scripts.
What’s needed for Mounjaro coverage?
Prior authorization and a qualifying diagnosis are often required. For weight loss, you may need a BMI of 30+ or related conditions. Your doctor must submit documentation.
How much does Mounjaro cost with Express Scripts?
If covered, copays range from $50 to $150, depending on the tier. Without coverage, it’s over $1,400 monthly. Savings cards may reduce costs.
Can I appeal a coverage denial?
Yes, you can appeal through Express Scripts’ process. Follow the denial letter’s instructions. Your doctor can provide supporting medical records.
Are there alternatives to Mounjaro for weight loss?
Yes, drugs like Wegovy or Zepbound may be covered. Discuss options with your doctor. Some plans require step therapy with other medications first.