Is Mounjaro Covered by Anthem?
Mounjaro is a medication gaining attention for managing type 2 diabetes and off-label weight loss. Many Anthem Blue Cross Blue Shield (BCBS) members ask, “Is Mounjaro covered by Anthem?” This article explains Anthem’s coverage for Mounjaro in simple terms.
What Is Mounjaro?
Mounjaro (tirzepatide) is an injectable drug approved by the FDA in 2022. It helps adults with type 2 diabetes control blood sugar. It mimics GLP-1 and GIP hormones to regulate glucose and appetite.
Many users experience weight loss, leading to off-label use. Mounjaro is given weekly via pens or vials. Its high cost makes insurance coverage crucial.
Anthem Blue Cross Blue Shield Overview
Anthem BCBS is a major health insurer operating in 14 states. It offers plans for individuals, families, and employers. Coverage varies by state, plan type, and formulary.
Anthem’s formulary lists covered drugs and their tiers. Mounjaro’s inclusion depends on your specific plan. Checking your plan details is the first step.
Mounjaro’s FDA Approval
Mounjaro is FDA-approved for type 2 diabetes, not weight loss. This affects insurance coverage, as plans prioritize approved uses. Weight loss is considered off-label.
Anthem is more likely to cover Mounjaro for diabetes. Coverage for weight loss is rare. Understanding this helps answer, “Is Mounjaro covered by Anthem?”
Anthem Coverage for Mounjaro
Anthem often covers Mounjaro for type 2 diabetes with prior authorization. Your doctor must show medical necessity, like failed trials of other drugs. Coverage typically requires an A1C above 7.
For weight loss, Anthem usually denies coverage. Some plans may cover Zepbound, a tirzepatide drug approved for weight loss. Check your formulary for specifics.
Comparison of Mounjaro and Zepbound Coverage
Here’s how Anthem may cover these drugs:
| Drug | Active Ingredient | FDA Approval | Anthem Coverage Likelihood |
|---|---|---|---|
| Mounjaro | Tirzepatide | Type 2 diabetes | High for diabetes, low for weight loss |
| Zepbound | Tirzepatide | Weight management | Limited, varies by plan |
This table clarifies coverage differences.
Prior Authorization Process
Anthem often requires prior authorization for Mounjaro. Your doctor submits documentation, like A1C levels or prior medication history. This proves Mounjaro is medically necessary.
The process can take days to weeks. Denials may occur if criteria aren’t met. Your doctor can appeal with additional evidence.
Steps to Check Coverage
To confirm if Mounjaro is covered by Anthem, follow these steps:
- Review Your Plan: Check your formulary on Anthem’s website or call customer service.
- Contact Anthem: Use the number on your insurance card to ask about Mounjaro.
- Talk to Your Doctor: They can verify coverage and handle prior authorization.
These steps clarify your coverage quickly.
Cost Without Coverage
Without insurance, Mounjaro costs about $1,069 monthly for four pens. This can range from $1,000 to $1,200 depending on the pharmacy. High costs make coverage essential.
Anthem’s coverage may reduce costs to a copay of $25–$900, based on your plan’s tier. Deductibles also affect out-of-pocket expenses.
Eli Lilly Savings Card
Eli Lilly offers a Mounjaro Savings Card for commercial insurance holders. Eligible patients pay as little as $25 for a 1–3 month supply. Anthem members with diabetes coverage may qualify.
The card saves up to $150 monthly or $1,800 annually. It doesn’t apply to weight loss or government plans. Check eligibility on Lilly’s website.
Why Coverage May Be Denied
Anthem may deny Mounjaro for several reasons. For diabetes, a low A1C (e.g., below 7) may lead to denial. Weight loss use is often excluded entirely.
Other denials stem from missing prior authorization or step therapy requirements. Step therapy mandates trying cheaper drugs first. Appeals can address denials.
Appealing a Denial
If Anthem denies coverage, you can appeal. Your doctor submits additional records, like lab results or treatment history. Some patients succeed after multiple appeals.
The process may take weeks and requires persistence. A health insurance attorney can help with complex cases. Check Anthem’s appeal process online.
Zepbound as an Alternative
Zepbound, also tirzepatide, is FDA-approved for weight loss. Some Anthem plans cover Zepbound for obesity with prior authorization. It costs about $1,059 monthly without insurance.
If Mounjaro is denied for weight loss, ask about Zepbound. Your doctor can assess its suitability. Coverage varies by plan and state.
Anthem’s Formulary Tiers
Anthem organizes drugs into tiers, affecting copays. Mounjaro is often Tier 2 or 3, meaning higher copays than generics. Tier 2 copays may be $50–$100, while Tier 3 can reach $900.
Check your plan’s tier system online. Lower tiers save money. Knowing Mounjaro’s tier helps estimate costs.
Coverage for Weight Loss
Anthem rarely covers Mounjaro for weight loss due to its off-label status. A 2024 lawsuit in Maine challenged Anthem’s obesity exclusion clause. It argued that denying weight loss drugs increases long-term costs.
Coverage for weight loss drugs like Zepbound is improving but limited. Only 25–43% of employers covered GLP-1 drugs for weight loss in 2024.
Other Covered Alternatives
If Mounjaro isn’t covered, Anthem may cover other diabetes drugs. Metformin, Trulicity, or Rybelsus are often preferred due to lower costs. These may require step therapy.
For weight loss, Wegovy may be covered with prior authorization. Discuss alternatives with your doctor. They can find a covered option.
Working with Your Doctor
Your doctor plays a key role in securing coverage. They submit prior authorization forms and appeal denials. They can also switch you to a covered drug like Zepbound.
Share your budget and goals with your doctor. They’ll tailor treatment to your plan. Regular communication ensures the best outcome.
Lifestyle Support for Mounjaro
Mounjaro works best with healthy habits. Eat a balanced diet with vegetables and lean proteins. Exercise, like walking 30 minutes daily, boosts results.
Anthem may cover nutrition counseling or diabetes programs. Ask about these benefits. Lifestyle changes enhance Mounjaro’s effectiveness.
Staying Informed
Anthem’s formulary changes yearly. Check updates on their website or call customer service. New policies may affect Mounjaro’s coverage.
Your doctor or pharmacist can also provide updates. Staying informed helps you plan treatment. Knowledge reduces unexpected costs.
Summary
Is Mounjaro covered by Anthem? For type 2 diabetes, Anthem often covers it with prior authorization, but coverage for weight loss is rare. Check your plan’s formulary, work with your doctor, and explore the Mounjaro Savings Card to lower costs. If denied, consider Zepbound or other covered drugs and appeal if needed.
FAQ
Is Mounjaro covered by Anthem for type 2 diabetes?
Yes, Anthem often covers Mounjaro for diabetes with prior authorization. Your doctor must show medical necessity, like an A1C above 7. Check your plan’s formulary.
Can Anthem cover Mounjaro for weight loss?
Anthem rarely covers Mounjaro for weight loss, as it’s off-label. Zepbound may be covered for obesity in some plans. Contact Anthem for details.
How do I know if Mounjaro requires prior authorization?
Call Anthem’s customer service or check your formulary online. Your doctor can confirm requirements. Prior authorization is common for Mounjaro.
What if Anthem denies Mounjaro coverage?
Your doctor can appeal with more documentation. Explore covered alternatives like Zepbound or Trulicity. A health insurance attorney may help with complex cases.