Step therapy is a process your health insurance provider may require before it will cover certain drugs. Many insurance providers require step therapy for Mounjaro (a drug prescribed for type 2 diabetes).
With step therapy, your insurance provider requires you to try a drug from its preferred medications list before it will cover a non-preferred drug.
Step therapy is also called “fail-first protocol.” This is because your insurance provider requires your doctor to confirm that one or more of the drugs on its preferred medications list were ineffective before it will cover certain other drugs. Preferred medications are often less expensive than non-preferred drugs.
The purpose of step therapy is to provide consumers with medications that work well and are safe and cost effective. However, step therapy is criticized by some as a way for insurance providers to spend less money.
Step therapy guidelines vary between insurance providers and states. Some insurance plans may require step therapy for a certain medication, while others don’t. The majority of states now have laws that limit when an insurance provider can require step therapy.
In some cases, you may be able to skip the step therapy process if your doctor requests prior authorization. Your doctor may request prior authorization in the following situations:
- You’ve already tried a preferred drug while covered under another insurance provider.
- You can’t take a preferred drug due to an allergy or other reason.
- Your doctor determines (for medical reasons) that you should try a non-preferred alternative.
Many health insurance providers have a step therapy requirement for Mounjaro.
For example, some plans may require you to try a generic type 2 diabetes drug, such as metformin, before it will cover Mounjaro (which is a brand-name drug). A generic contains an exact copy of the active drug in a brand-name medication. A generic is considered just as safe and effective as the original drug but tends to cost less.
Or in other cases, you may have to try a less expensive brand-name drug from your insurance provider’s preferred drug list before it will cover Mounjaro. To find out which drugs are preferred versus non-preferred, check your health plan documents or call your insurance provider.
It’s also important to note that your insurance provider may only cover Mounjaro if you’re using it to treat type 2 diabetes. The drug can also be prescribed off-label for weight loss. (To learn more, see the section below.)
Mounjaro is approved by the Food and Drug Administration (FDA) for managing blood sugar in people with type 2 diabetes. However, the drug can also be prescribed off-label for weight loss. (With off-label use, doctors prescribe a drug for a purpose other than what it’s approved for.)
Most health insurance providers do not cover medications used solely for weight loss. For example, Medicaid and Medicare generally do not cover weight-loss medications. Because of this, it’s important to check your specific plan benefits before starting Mounjaro treatment for weight loss.
Another drug called Zepbound contains the same active ingredient as Mounjaro and is FDA-approved for weight loss. Some insurance providers may cover Zepbound for weight loss, although many don’t.
How much does Mounjaro cost without insurance?
If you’re interested in using Mounjaro for weight loss and your health plan doesn’t cover this use, check out these Optum Perks coupons. (Note: Optum Perks coupons cannot be used with any insurance copays or benefits.)
Save on Mounjaro with Optum Perks
Save on Mounjaro without insurance.
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Location
47201
Dosage
4 mounjaro (3 Packages)
Save money without using insurance
Simply show the Optum Perks coupon at your preferred pharmacy or order online and instantly save up to 80% without using insurance. The coupon doesn’t expire, so be sure to save it for refills.
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Retail price refers to the manufacturer’s published list price and is up to date as of 3/2023. Retail and discounted prices are U.S.-only and can vary based on region and pharmacy. We cannot guarantee that the discounted price listed here will exactly match the price at your pharmacy. Please contact your pharmacy for the exact price.
Optum Perks and Healthline are subsidiaries of RVO Health.
Pricing source:Perks.optum.com
Mounjaro is a type of drug called a GLP-1 receptor agonist. The step therapy requirements for other GLP-1 medications are often similar to those of Mounjaro.
To learn which drugs prescribed for type 2 diabetes have a step therapy requirement, check your specific health insurance benefits or talk with your doctor.
Some health insurance providers require step therapy for Mounjaro. This means you may have to try a drug from its preferred medications list before it will cover a non-preferred drug.
Before starting Mounjaro treatment, it’s important to check your coverage details with your insurance provider.