Does Medicare cover Mounjaro?

In this article:

• How much does Mounjaro cost?
• Does Medicare cover Mounjaro?
• Factors affecting the cost of Mounjaro with Medicare
• Paying for Mounjaro
• How to save on Mounjaro

In this article

• How much does Mounjaro cost?
• Does Medicare cover Mounjaro?
• Factors affecting the cost of Mounjaro with Medicare
• Paying for Mounjaro
• How to save on Mounjaro

Mounjaro is a popular brand-name medication approved by the Food and Drug Administration (FDA) to improve blood sugar control in people with Type 2 diabetes, along with diet and exercise. One common side effect of Mounjaro is weight loss, which is why it may sometimes be prescribed off-label (for a non-FDA-approved use) for that purpose. Tirzepatide, the active ingredient of Mounjaro, is approved for weight loss under the brand name Zepbound. 

“Tirzepatide works in your body by targeting two important hormones called glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1),” says Alyssa M. Wozniak, Pharm.D., assistant dean for clinical affairs, outreach, and special projects at the School of Pharmacy at D’Youville University. “By targeting these hormones, Mounjaro helps your body release more insulin when your blood sugar is high. This helps lower your blood sugar levels and reduces the amount of another hormone called glucagon, which can raise blood sugar levels.”

Mounjaro also slows gastric emptying so you feel full longer, according to Sarah Bonza, MD, of Bonza Health. Studies have shown that people who take Mounjaro lose significant weight, which is why it has sometimes been in short supply, according to Dr. Bonza. Due to its popularity, some people may wonder whether it’s covered by their health insurance plans, including Medicare. Although it’s likely to be covered for Type 2 diabetes, don’t expect Medicare to cover Mounjaro for weight loss alone.

How much does Mounjaro cost?

Mounjaro is expensive. Without help from your health insurance plan, Medicare Part D, or Medicaid, you can expect to pay the typical retail price of $1,476 for a 28-day supply (a pack of four pens). The drug comes in six strengths: 2.5 mg, 5 mg, 7.5mg, 10 mg, 12.5 mg, and 15 mg. Depending on where you get your prescription filled, though, the price can vary a lot. In fact, prices can vary by hundreds of dollars between pharmacies—even when they are in the same town, according to a Consumer Reports survey. A study published in 2022 found “significant price variation in community pharmacies.”

How much you pay for Mounjaro depends on a variety of factors, such as what type of insurance you have. Medicaid, the state- and federally funded program that provides free or steeply discounted health insurance, sometimes covers Mounjaro for Type 2 diabetes but not typically for weight loss. How much a person with Medicaid will pay for Mounjaro depends on the state’s cost-sharing requirements, such as copays and deductibles, and whether Mounjaro is one of their “preferred” drugs. In 2022, Medicaid dispersed nearly $30 million to help beneficiaries pay for Mounjaro.

Does Medicare cover Mounjaro?

Medicare Part D or Medicare Advantage plans may cover Mounjaro, but a number of factors come into play. For one, whether it is covered by Medicare depends on why it is prescribed.

“If your doctor prescribed it to treat Type 2 diabetes, it may be covered by most insurance and Medicare prescription drug plans. If it is prescribed so that a person can lose weight, Medicare won’t cover it,” says Selly Vazquez, founder of SV Insurance Company and an Associate of Medicare Resource Group in Brookfield, Connecticut. “This is ironic,” Vazquez says, “since obesity may lead to diabetes.”

Even if prescribed for Type 2 diabetes, Mounjaro may be considered a “non-preferred” medication with some Medicare Part D plans, which could require you to get prior authorization to get it covered, or you may be asked to try an alternative, cheaper medication first, a restriction known as step therapy.

Factors affecting the cost of Mounjaro with Medicare

What you ultimately will pay for Mounjaro on Medicare depends on various factors, such as your specific Medicare prescription drug plan. On every insurance plan is a list of covered drugs known as a formulary. Formularies are different depending on what plan you have, but in each case, drugs are assigned certain levels, called “tiers,” on their formularies. The drugs in a particular tier each have a different cost. “Drugs in the lower tiers typically cost less than drugs in higher tiers,” Vazquez explains.

Drug formularies may change what tier they assign a particular drug at any time. You may want to compare the formulary of several plans during the next Open Enrollment Period. Then, you can choose the plan that best suits your specific needs, and you may find a plan that covers Mounjaro.

Paying for Mounjaro

There is good news on the horizon about out-of-pocket spending on prescription drugs like Mounjaro. In 2024, once your out-of-pocket spending on prescription drugs tops a certain amount, you would enter Medicare Part D’s “catastrophic coverage” phase and pay nothing for your covered Part D drugs for the remainder of the year, although you would still need to pay for your Part D premium. But in 2025, people who have Part D will not have to pay more than $2,000 in out-of-pocket costs. This is thanks to a provision in the Inflation Reduction Act of 2022. This $2,000 cap is expected to save money for some Medicare beneficiaries, especially those who take expensive brand-name drugs like Mounjaro. 

Additionally, in 2025, for the first time, Medicare recipients will have a different payment option to pay for prescription drugs. The Inflation Reduction Act applies to all Medicare prescription drug plans—whether standalone Medicare Part D plans or Medicare Advantage plans with prescription drug coverage. They will be required to offer the option to pay out-of-pocket prescription drug costs in the form of capped monthly installment payments instead of all at once at the pharmacy.

How to save on Mounjaro

You may be able to make Mounjaro more affordable with a SingleCare prescription discount card, which provides you access to Mounjaro coupons at over 35,000 participating pharmacies around the country. For instance, you could pay $998 for a month’s supply of Mounjaro instead of the average retail price of $1,476 with a Mounjaro coupon, depending on your choice of pharmacy. 

If you qualify for Medicare Extra Help, the program can help pay for your Medicare Part D premiums, deductibles, coinsurance, and other costs. Some people qualify for the program automatically, while others have to apply. You get Extra Help automatically if you have full Medicaid coverage, state assistance for Part B premiums, or supplemental security income from Social Security. There’s no Part D late enrollment penalty while you receive Extra Help. 

RELATED: 5 Mounjaro savings tips