CVS Caremark Mounjaro Prior Authorization: 2026 Criteria, Denials, and What to Do Next
The exact A1C cutoffs, both criteria templates decoded, the phone/fax lines, a denial translator, and who to call first — based on your situation.
Disclosure: The RX Index is a pricing intelligence and comparison resource for GLP-1 telehealth providers. We may earn a commission when you start care through some provider links. It costs you nothing extra, and it never changes a plan’s rules or our recommendations — your coverage and your eligibility are decided by your health plan and your clinician, not by us.
Bottom line: CVS Caremark Mounjaro prior authorization is almost always a type 2 diabetes review — not a weight-loss approval. The strongest path is a documented type 2 diabetes diagnosis with a qualifying lab: an A1C of 6.5% or higher, or a fasting blood sugar of 126 mg/dL or higher after an 8-hour fast. If your goal is Mounjaro for weight loss, expect a denial. The on-label tirzepatide for weight loss is Zepbound, not Mounjaro.
Find your situation first
| Your situation | Most likely CVS Caremark path | Biggest denial risk | Best first move |
|---|---|---|---|
| You have type 2 diabetes and your doctor prescribed Mounjaro | Diabetes (antidiabetic GLP-1) prior authorization | Missing labs or undocumented diagnosis | Ask your prescriber to submit the diabetes diagnosis plus the A1C/glucose proof |
| You've been on Mounjaro a while and need a renewal | Continuation review | Renewal sent like a brand-new request with no proof it's working | Send dose history, A1C trend, and refill records |
| You want Mounjaro for weight loss (no diabetes) | Usually the wrong drug to ask for | No qualifying diabetes diagnosis | Ask about Zepbound -- the on-label tirzepatide for weight loss |
| Your app says "covered, but PA required" | Plan-specific diabetes PA | Assuming a public PDF equals your exact plan rule | Call CVS Caremark and ask which criteria apply to your member ID |
| Your letter says "plan exclusion" | A benefit-design issue, not a paperwork issue | Resubmitting the same request when the drug simply isn't covered | Get the denial in writing; ask about an exception or appeal |
| You have obesity plus moderate-to-severe sleep apnea | Zepbound sleep-apnea path (not Mounjaro) | Missing sleep study or BMI proof | Build a Zepbound packet, not a Mounjaro one |
The honest part most pages skip: No website can promise your exact plan will approve Mounjaro. CVS Caremark publishes criteria, but your employer can customize coverage. This guide gives you the documents to gather and the questions to ask before anyone resubmits — so you don’t burn a week on a request missing one lab.
Why you may see different CVS Caremark criteria online
CVS Caremark has more than one public criteria template for these diabetes medicines, and they differ in two big ways: how they decide, and how long approval lasts. Your plan picks which one applies to you.
| Where you’ll find it | Reference # | Approval length | How it decides | What to do |
|---|---|---|---|---|
| CVS Caremark’s PA forms hub | 5694-D (“with Logic”) | 36 months | Uses “screen-out logic”: a type 2 diabetes code on your pharmacy claim can mean no prior authorization at all. PA only kicks in if that’s missing. | Ask whether this version applies to your member ID |
| A separate CVS-hosted criteria PDF | 5496-C (“with Limit”) | 12 months | Spells out initial and renewal criteria, asks about prior GLP-1 use, and adds quantity limits | Don’t assume 12 months unless your plan uses this version |
The good news: the lab thresholds are the same in both templates (the A1C and glucose numbers below). The differences are how the approval is triggered and how long it lasts. Confirm your plan’s version and you’ll know which rules actually govern you.
The exact CVS Caremark Mounjaro prior authorization criteria for 2026
Quick answer: CVS Caremark’s published rules list Mounjaro under the type 2 diabetes pathway. To approve it, your records must show a type 2 diabetes diagnosis plus one qualifying result: an A1C of 6.5% or higher, a 2-hour glucose of 200 mg/dL or higher on a glucose tolerance test, a random glucose of 200 mg/dL or higher with high-blood-sugar symptoms, or a fasting glucose of 126 mg/dL or higher after an 8-hour fast.
These criteria come straight from CVS Caremark’s own published coverage documents (ref 5694-D and 5496-C). Last verified .
Quick vocabulary check
| Term | Plain English |
|---|---|
| Prior authorization (PA) | Your plan's approval step before it will pay for a medicine |
| Tirzepatide | The active ingredient in both Mounjaro and Zepbound |
| A1C | A blood test showing your average blood sugar over about 3 months |
| Formulary | The list of drugs your plan covers |
The lab proof that qualifies you (same across both templates)
To approve Mounjaro for type 2 diabetes, CVS Caremark wants your records to show at least one of these — and the criteria literally say documentation is required:
| Qualifying lab / result | Threshold | Notes |
|---|---|---|
| A1C (hemoglobin A1C) | 6.5% or higher | Most common qualifying result; must include the value and date |
| Fasting plasma glucose | 126 mg/dL or higher | After at least 8 hours of fasting; confirm the fast in the packet |
| 2-hour glucose (OGTT) | 200 mg/dL or higher | On an oral glucose tolerance test |
| Random glucose with symptoms | 200 mg/dL or higher | Must be accompanied by high-blood-sugar symptoms: excessive thirst, frequent urination, increased hunger |
The catch is the word “documented.” A note that simply says “patient has diabetes” often isn’t enough. The packet needs the actual lab value, the date, the diagnosis code, and a progress note. Missing labs are one of the most common — and most fixable — reasons a clean-looking request stalls.
The part that depends on your plan’s template
If your plan uses the “with Logic” version (5694-D): If your pharmacy claim is submitted with a type 2 diabetes diagnosis code, Mounjaro can simply be paid with no prior authorization at all. The PA step only triggers if your claim doesn’t show a diabetes code (and you don’t have a recent history of diabetes medicines on file). If it triggers, the lab criteria above apply, and approval can last 36 months.
If your plan uses the “with Limit” version (5496-C): This one asks whether you’ve already been on a steady dose of another GLP-1 medicine for at least 3 months. If you haven’t, you’re on the “new start” path with the lab criteria above. If you have, you’re on the renewal path (below). Approval typically lasts 12 months, with quantity limits.
Renewals: what changes
If your plan uses a renewal step, the packet is different from a first request:
- You’ve been on a steady dose for at least 3 months
- Your diabetes diagnosis still stands
- Proof it’s working — most commonly that your A1C has come down since you started
Trick that trips people up: What if Mounjaro worked so well your A1C is now under 6.5%? That’s a win, not a problem — but the renewal needs to show your original diabetes evidence plus your A1C drop since starting therapy. Don’t let the office submit it as a brand-new request, or it can get judged against the wrong rule.
Want Mounjaro for weight loss? Read this before you fight a denial
Quick answer: Mounjaro is FDA-approved to improve blood sugar in type 2 diabetes — it is not an FDA-approved weight-loss drug. Insurance generally follows the FDA-approved use, so a weight-loss-only request for Mounjaro is usually denied. The on-label tirzepatide for weight loss is Zepbound, which has its own separate CVS Caremark criteria based on BMI and a weight-management program.
Insurance doesn’t pay based on the molecule — it pays based on the FDA-approved use. Mounjaro’s approved use is type 2 diabetes. That’s why insurance review boards routinely deny Mounjaro when the only diagnosis on the form is obesity.
Mounjaro vs. Zepbound vs. Wegovy — for insurance purposes
| Drug | Active ingredient | FDA-approved use that matters here | The CVS Caremark lens |
|---|---|---|---|
| Mounjaro | Tirzepatide | Type 2 diabetes (blood sugar) | Diabetes criteria -- needs diabetes labs |
| Zepbound | Tirzepatide | Chronic weight management; also moderate-to-severe sleep apnea with obesity | Weight-management criteria -- needs BMI + a weight program |
| Wegovy | Semaglutide | Chronic weight management | Often a preferred weight-loss option on commercial plans |
Zepbound’s CVS Caremark criteria, in plain English (ref 6947-C)
- A reduced-calorie diet and more physical activity, and
- Participation in a comprehensive weight-management program (typically documented over about 6 months), and
- A BMI of 30 or higher, or 27 or higher with a weight-related condition (like high blood pressure or high cholesterol), and
- Documentation for all of it
For the sleep-apnea path, Zepbound criteria add a moderate-to-severe diagnosis with an AHI of 15 or higher on a sleep study, plus a BMI of 30 or higher.
The big 2026 update most pages haven’t caught up to
- Zepbound returns to CVS Caremark commercial formularies on October 1, 2026 as an additional preferred option alongside Wegovy (CVS Health newsroom, May 28, 2026). Your employer can still choose not to cover weight-loss drugs at all.
- Foundayo (orforglipron) — the new oral GLP-1 pill — block lifted June 1, 2026.
- Medicare GLP-1 Bridge: July 1, 2026 through December 31, 2027, $50 copay for eligible Part D members for Foundayo, Wegovy (injection and tablets), and the Zepbound KwikPen — weight-management use only. Does not apply to Mounjaro or to diabetes coverage.
Weight-loss goal, want the paperwork handled?
Ro’s free GLP-1 Insurance Coverage Checker reports whether your CVS Caremark plan covers Zepbound and whether a prior authorization is required. Ro’s concierge then submits the PA and works denials. Ro does not carry Mounjaro. Medicaid isn’t eligible for Ro’s treatment program.
Check my CVS Caremark coverage for Zepbound → free (sponsored affiliate link, opens in a new tab)For weight-loss tirzepatide. Ro does not offer Mounjaro.
What your doctor needs to send — the “don’t get denied for paperwork” checklist
Print this. Hand it to your prescriber’s office before they submit or resubmit. The cleaner the first submission, the faster the answer.
Every Mounjaro PA should include:
- Your name, date of birth, and insurance member ID
- The drug requested: Mounjaro (tirzepatide), with the dose
- Your type 2 diabetes diagnosis and its ICD-10 code (for type 2 diabetes it usually starts with E11)
- The qualifying lab value and date -- your A1C, or your fasting/random/glucose-tolerance result
- A note confirming the 8-hour fast if a fasting glucose is the qualifying result
- Your history with other GLP-1 medicines (which, how long, what happened)
- A short clinical reason Mounjaro is appropriate for you
For a renewal, add:
- Your prior approval and refill history
- Your current steady dose and how long you've been on it
- Your A1C trend (the proof it's working)
- Confirmation your diabetes diagnosis still stands
How the CVS Caremark prior authorization process works
You don’t submit the PA yourself — your prescriber’s office supplies the clinical answers. But you can absolutely push it along, and you should.
Who submits it, and how fast
| Submission method | Speed | Notes |
|---|---|---|
| ePA (electronic prior authorization) | Fastest -- some automated decisions in under 6 seconds | CVS Caremark confirms; several times faster than fax or phone |
| Fax | Slower | Easier to lose pages; confirm receipt |
| Phone | Variable | For when the other two aren't an option |
The verified CVS Caremark prior authorization phone and fax lines
Verified from CVS Caremark’s prior authorization page. Hours: Monday–Friday, 8 a.m.–6 p.m. CST. Last verified .
| Plan type | Phone | Fax |
|---|---|---|
| Non-Medicare (most commercial/employer plans) | 1-800-294-5979 | 1-888-836-0730 |
| Medicare Part D | 1-855-344-0930 | 1-855-633-7673 |
| Medicaid | 1-877-433-7643 | 1-866-255-7569 |
Your CVS Caremark call script
Before your doctor resubmits, a five-minute call can save you weeks. Ask these, in order, and write down the answers:
- Which Mounjaro criteria apply to my member ID -- the "with Logic" version (5694-D) or the "with Limit" version (5496-C)?
- Is Mounjaro on my formulary, non-formulary, excluded, or covered with a PA?
- Was my denial clinical (missing medical info), administrative (paperwork), or a plan exclusion (not covered at all)?
- Can my prescriber resubmit with the missing information?
- Is a formulary exception available for me?
- What's the appeal deadline printed on my denial letter?
- If weight loss is my goal, is Zepbound covered under my plan, and what are its criteria?
How long does CVS Caremark Mounjaro prior authorization take?
There’s no single guaranteed clock for everyone. What you can control is completeness.
| Scenario | Typical timeline |
|---|---|
| ePA with correct diagnosis code (screen-out logic) | Seconds to minutes -- some automated decisions under 6 seconds |
| Complete electronic submission, no missing docs | Often within 72 hours |
| Urgent request (expedited) | Faster -- ask your prescriber to mark it urgent |
| Missing a lab or diagnosis code | Clock resets -- can add days or weeks |
| Managed by a telehealth service (e.g. Ro for Zepbound) | A few weeks end to end; plan around the stated timeline |
Denied? Here’s exactly what to do
Before anything else, get the denial in writing. It should tell you the reason, the criteria used, the appeal instructions, and your deadline. Then match the wording to this decoder.
The CVS Caremark denial decoder
| What the letter says | What it usually means | Your best next step |
|---|---|---|
| "Prior authorization required" | The PA wasn't submitted or wasn't finished | Have your prescriber submit the criteria answers |
| "Insufficient documentation" | A lab, diagnosis, or note is missing | Resubmit with the specific missing record |
| "Not medically necessary" | The criteria weren't met or weren't shown | Ask for the exact criteria, then add the clinical proof |
| "Not covered for your condition" | Wrong drug for the use (e.g., Mounjaro for weight loss) | Switch to the Zepbound path if your goal is weight loss |
| "Plan exclusion" | Your benefit may not cover this drug at all | Ask about an exception or appeal; your employer plan controls this |
| "Try formulary alternative" | Step therapy or a preferred drug comes first | Ask which alternative, and what the exception rule is |
| "Comprehensive weight-management program not met" | This is a weight-loss (Zepbound-style) criterion being applied | Build a Zepbound packet, not a Mounjaro diabetes one |
Resubmit, or appeal? They’re not the same
Missing or incomplete information? A resubmission with the missing labs is usually faster and cleaner than a formal appeal. Fix the gap and send it back.
Medical necessity, formulary exclusion, or step therapy — and documentation is already complete? An appeal is your route.
Your deadlines — don’t miss them
- Under federal rules for most private-sector employer plans: at least 180 days after a denial to file an internal appeal.
- External review (independent reviewer): typically 45 days for standard cases, or as fast as 72 hours for urgent ones.
- Those federal rules apply to many employer (ERISA) plans — not to Medicare, Medicaid, or FEHB plans, which have their own timelines.
- Go by your denial letter, not a general rule. Your exact deadline is on it.
What Mounjaro costs — whether CVS Caremark approves it or not
The list price before insurance runs around $1,090 a month, and cash prices at the pharmacy commonly run $1,080–$1,300 for a month of pens.
| Situation | Lilly savings card | Key caveat |
|---|---|---|
| Commercial insurance that covers Mounjaro | As little as $25/month for an eligible patient (up to $1,950/year) | Requires commercial insurance, age 18+, U.S. or Puerto Rico, prescription for approved use |
| Commercial insurance that does NOT cover Mounjaro | As low as $499/month for an eligible patient | Card still requires commercial insurance -- not for government plans |
| Medicare, Medicaid, TRICARE, or VA | Not eligible for the Mounjaro Savings Card | Don't rely on coupon workarounds. The card expires 12/31/2026. |
Calendar note: If you were denied and weight loss is the goal, the lower-cost, on-label route is Zepbound — and Zepbound returns to CVS Caremark’s most common commercial drug lists October 1, 2026, which may change your covered cost entirely. Before you commit to paying full price, find out whether you’re one formulary update or one corrected lab away from a covered prescription.
See full breakdown: Mounjaro cost without insurance →
Who can actually help you get Mounjaro covered
Let’s match you to the right door so you stop spinning your wheels.
If you have type 2 diabetes and need Mounjaro
Start with your own primary care doctor or endocrinologist. They already have your A1C history and your diagnosis on file — exactly what a clean PA needs. Using your CVS Caremark benefit through your own doctor is almost always cheaper than any cash-pay alternative.
If you don’t have a doctor managing your diabetes, or you want a faster telehealth option, Sesame offers online type 2 diabetes visits and can prescribe Mounjaro when a clinician decides it’s right for you. Sesame’s providers can also help with the prior-authorization paperwork. (A licensed clinician makes the call — no platform can promise a prescription.)
See Sesame’s online type 2 diabetes visit options →
For type 2 diabetes evaluation. A licensed clinician decides if Mounjaro is appropriate.
If your real goal is tirzepatide for weight loss
Then Zepbound — not Mounjaro — is your on-label path, and Ro is built for exactly this. Ro’s insurance concierge checks your coverage and submits the prior-authorization paperwork for you, and its free coverage checker tells you whether your plan covers each GLP-1 and whether a PA is required. Ro doesn’t carry Mounjaro, and Medicaid isn’t eligible for treatment through Ro.
Quick routing table
| What you need | Better route | Why |
|---|---|---|
| Mounjaro for type 2 diabetes | Your primary care doctor / endocrinologist, or Sesame | They have (or can build) the diabetes labs and diagnosis |
| Tirzepatide for weight loss | Ro (Zepbound) | On-label weight-loss tirzepatide + PA paperwork handled |
| Someone to handle the insurance paperwork | Ro insurance concierge | Submits PAs and works denials for eligible brand-name GLP-1s |
| Online diabetes prescription evaluation | Sesame | Online type 2 diabetes visits; can prescribe Mounjaro when appropriate |
| Not sure what fits | The RX Index matcher | A personalized plan before you pick a drug or provider |
Mounjaro safety facts to know first
Mounjaro is a prescription medicine, and whether it’s right for you is a clinical decision, not just an insurance one. This page is not medical advice.
Mounjaro is FDA-approved as an adjunct to diet and exercise to improve glycemic control (blood sugar) in adults and pediatric patients 10 years and older with type 2 diabetes.
The boxed warning (the FDA’s most serious warning): In animal studies, tirzepatide caused thyroid C-cell tumors in rats. It’s not known whether Mounjaro causes these tumors, including medullary thyroid carcinoma (MTC), in humans.
Do not use Mounjaro if you have:
Do not use Mounjaro if you have:
- A personal or family history of MTC or the genetic condition MEN 2 (Multiple Endocrine Neoplasia syndrome type 2)
- A known serious allergy to tirzepatide or the medicine’s ingredients
Also discuss with a clinician: pancreatitis, gallbladder problems, kidney injury from dehydration, severe stomach and intestinal reactions, worsening of existing diabetic eye disease, low blood sugar if combined with insulin or certain diabetes pills, and care around surgery or anesthesia. Tell your doctor about thyroid-tumor symptoms like a lump in the neck, trouble swallowing, shortness of breath, or lasting hoarseness. Don’t combine tirzepatide products or use it with another GLP-1 at the same time. Read the full FDA Medication Guide and talk it through with your prescriber.
How we put this guide together
Built from primary sources: CVS Caremark’s published PA criteria, the FDA Mounjaro label, Eli Lilly’s savings terms, CMS, and current Ro and Sesame provider pages. Last verified: .
| What we verified | What it says | Last checked |
|---|---|---|
| CVS Caremark criteria, ref 5694-D ("with Logic") | Screen-out logic; 36-month approval; same lab thresholds | June 10, 2026 |
| CVS Caremark criteria, ref 5496-C ("with Limit") | Initial/continuation criteria; 12-month approval; quantity limits | June 10, 2026 |
| CVS Caremark Zepbound criteria, ref 6947-C | BMI and weight-management program rules; sleep-apnea AHI rule | June 10, 2026 |
| CVS Caremark PA page | Submission routes; phone/fax lines; hours | June 10, 2026 |
| FDA Mounjaro label | Type 2 diabetes indication; boxed warning; contraindications | June 10, 2026 |
| Eli Lilly savings terms | $25 covered / $499 not-covered / government excluded | June 10, 2026 |
| CVS Health newsroom (May 28, 2026) | Zepbound returns Oct 1, 2026; Foundayo block lifted June 1, 2026 | June 10, 2026 |
| CMS Medicare GLP-1 Bridge | $50 copay; weight-management drugs only; not Mounjaro | June 10, 2026 |
| Ro provider pages | Free coverage checker; concierge submits PAs; does not offer Mounjaro | June 10, 2026 |
| Sesame provider page | Online type 2 diabetes visits; can prescribe Mounjaro; PA help | June 10, 2026 |
What we could not verify for you (only your plan and clinician can): your employer’s specific customizations, your member-specific formulary and copay, whether your doctor will prescribe, and whether CVS Caremark will approve your request.
CVS Caremark Mounjaro prior authorization FAQ
- Does CVS Caremark cover Mounjaro?
- Sometimes -- it depends on your plan and formulary. When covered, Mounjaro typically requires prior authorization under CVS Caremark's antidiabetic GLP-1 criteria, and the strongest path is a documented type 2 diabetes diagnosis. Under one CVS criteria template, a claim with a type 2 diabetes code can even be paid without a prior authorization at all.
- What diagnosis qualifies for Mounjaro prior authorization?
- Type 2 diabetes with supporting lab proof is the strongest published CVS Caremark pathway. Weight-loss-only requests are usually denied because Mounjaro is not an FDA-approved weight-loss drug.
- What A1C does CVS Caremark look for?
- CVS Caremark's criteria list a history of an A1C of 6.5% or higher as one qualifying option, along with alternatives like a fasting glucose of 126 mg/dL or higher after an 8-hour fast, or a glucose of 200 mg/dL or higher on certain tests.
- Why do I see different CVS Caremark Mounjaro criteria online?
- CVS Caremark publishes more than one criteria template. One ("with Logic," reference 5694-D) uses screen-out logic and lists a 36-month approval; another ("with Limit," reference 5496-C) spells out initial and renewal criteria and lists a 12-month approval. The lab thresholds are the same; your plan decides which version applies.
- Can I get Mounjaro approved for weight loss through CVS Caremark?
- Usually not. Mounjaro is FDA-approved for type 2 diabetes. The on-label tirzepatide for weight loss is Zepbound, which has separate CVS Caremark criteria based on BMI and a weight-management program.
- What if my A1C dropped below 6.5% because Mounjaro is working?
- For a renewal, the packet should show your original diabetes evidence plus your A1C reduction since starting therapy. A lower A1C is proof the medicine is working -- make sure it's submitted as a continuation, not a brand-new request.
- Can my doctor resubmit a denied Mounjaro prior authorization?
- Yes. If the denial was for missing or incomplete information, resubmitting with the missing labs is often the fastest fix. Your denial letter tells you exactly what is needed.
- What is the CVS Caremark prior authorization phone or fax number?
- It depends on your plan. Non-Medicare: phone 1-800-294-5979, fax 1-888-836-0730. Medicare Part D: phone 1-855-344-0930, fax 1-855-633-7673. Medicaid: phone 1-877-433-7643, fax 1-866-255-7569. Hours are Monday to Friday, 8 a.m. to 6 p.m. CST.
- How long does CVS Caremark prior authorization take?
- Electronic requests can return a decision in minutes; CVS Caremark says some automated decisions come back in under six seconds. Many plans decide non-urgent requests within about 72 hours of a complete request, but your plan controls the actual timeline, and missing documents reset the clock.
- Is Zepbound back on CVS Caremark?
- CVS Health announced that CVS Caremark will add Zepbound back to its most common commercial formularies as an additional preferred option on October 1, 2026. Plan sponsors can still customize or exclude coverage.
- Does Ro help with a CVS Caremark Mounjaro prior authorization?
- Ro's insurance concierge handles GLP-1 prior-authorization paperwork when required, but Ro does not currently offer Mounjaro, and Medicaid isn't eligible for treatment through Ro. Use Ro for Zepbound or other eligible brand-name weight-loss coverage support -- not as a Mounjaro promise.
- Does Sesame offer Mounjaro?
- Yes -- Sesame has online type 2 diabetes visits and can prescribe Mounjaro when a clinician decides it's appropriate, and its providers can assist with prior-authorization paperwork.
- Can I use a Lilly savings card if CVS Caremark denies Mounjaro?
- Possibly, if you have commercial insurance, a prescription for an approved use, and meet Lilly's terms -- as low as $499 per month when your plan doesn't cover it. People with Medicare, Medicaid, TRICARE, or VA coverage aren't eligible for the savings card.
Still not sure which GLP-1 program is right for you?
Take our free 60-second matching quiz and get a personalized action plan — diabetes path, Zepbound path, appeal, or cash-pay — based on your actual situation.
Get my personalized GLP-1 action plan →Weight-loss goal? Check Zepbound coverage on Ro → (sponsored affiliate link, opens in a new tab)By The RX Index Editorial Team. This article is for general information and is not medical advice or a guarantee of insurance coverage. Medication decisions are made by licensed clinicians; coverage decisions are made by your health plan. Always read the FDA Medication Guide and talk with your prescriber. Last verified: .
Related guides
- → Does CVS Caremark cover Mounjaro? Verified 2026 PA criteria
- → Blue Cross Mounjaro prior authorization
- → Best GLP-1 providers that help with prior authorization
- → Free GLP-1 insurance coverage checker
- → GLP-1 formulary tier explained: 2026 cost decoder
- → Mounjaro cost without insurance
- → Free 60-second GLP-1 matching quiz
Sources
- CVS Caremark -- Antidiabetic GLP-1, GIP-GLP-1 Agonist PA "with Logic," ref 5694-D (screen-out logic; 36-month approval)
- CVS Caremark -- Antidiabetic GLP-1, GIP-GLP-1 Agonist PA "with Limit," ref 5496-C (initial/continuation criteria; 12-month approval; lab thresholds)
- CVS Caremark -- Tirzepatide (Zepbound) weight-management PA criteria, ref 6947-C (BMI, program, sleep apnea)
- CVS Caremark -- Prior Authorization page (process; verified phone/fax lines; hours)
- CVS Health Newsroom -- "CVS Caremark delivers affordability and access to GLP-1 weight management medications" (May 28, 2026; Zepbound back Oct 1, 2026; Foundayo block lifted June 1, 2026)
- FDA -- Mounjaro (tirzepatide) Prescribing Information / boxed warning and contraindications
- Eli Lilly -- Mounjaro Savings & Coverage terms ($25 / $499 / government exclusion)
- CMS -- Medicare GLP-1 Bridge ($50 copay; July 1, 2026-Dec 31, 2027; Foundayo, Wegovy injection/tablets, Zepbound KwikPen; weight-management use only)
- Ro -- GLP-1 Insurance Coverage Checker and Weight Loss program & insurance concierge
- Sesame -- Mounjaro online (type 2 diabetes; PA paperwork assistance)
- U.S. Department of Labor -- Benefit Claims Procedure Regulation FAQs (180-day appeal window; external review timelines; applies to ERISA plans)