The facts
Weight loss
Generally no
Type 2 diabetes
Yes, with step therapy or PA
Prior auth
Typical (step therapy, PA if not met)
Typical cost
Plan-specific
The criteria, as published
5 of 9 criteria are stated in the CVS Caremark documents we read. Tap a row for the exact wording. Where a cell says not published, the documents we read do not say, and the line under it is how to find out.
- Formulary status
Preferred brand (PB) on the 2026 Standard Control plan drug guide (Aetna edition, Oct 2026)
“PB = Preferred Brands … MOUNJARO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.5ML, 12.5 MG/0.5ML, 15 MG/0.5ML, 2.5 MG/0.5ML, 5 MG/0.5ML, 7.5 MG/0.5ML (tirzepatide) PB”
fm.formularynavigator.com · 2026 plan year- BMI threshold
- Not published in what we readAsk member services for the written prior authorization criteria for Mounjaro.
- Qualifying conditions
Type 2 diabetes
“Authorization may be granted for a diagnosis of type 2 diabetes mellitus when the following criteria is met: … The patient has experienced an inadequate treatment response, intolerance, or has a contraindication to metformin … The patient requires combination therapy AND has an A1C of 7.5 percent or greater”
aetna.com · 2024-10-27- Lifestyle program
- Not published in what we readAsk whether a diet, exercise or behavioral program has to be documented, and for how long.
- Step therapy
Metformin first, unless combination therapy is needed with A1C 7.5%+
“Authorization may be granted for a diagnosis of type 2 diabetes mellitus when the following criteria is met: … The patient has experienced an inadequate treatment response, intolerance, or has a contraindication to metformin … The patient requires combination therapy AND has an A1C of 7.5 percent or greater”
aetna.com · 2024-10-27- Quantity limit
4 pens per 21 days, or 12 per 63 days
“4 single-dose pens or single-dose vials (2 mL) per 21 days* OR 12 single-dose pens or single-dose vials (6 mL) per 63 days*”
aetna.com · 2024-10-27- Renewal
Stable dose for 3+ months and a drop in A1C since starting
“CONTINUATION OF THERAPY … The patient has been receiving a stable maintenance dose of the requested drug for at least 3 months … The patient has demonstrated a reduction in A1C since starting this therapy”
aetna.com · 2024-10-27- Plan can exclude it?
- Not published in what we readAsk HR or member services whether your plan includes the weight-loss drug benefit.
- 2026 change
- Not published in what we readAsk whether Mounjaro's status changed this year or changes at your next renewal.
Who actually decides this
Not the logo on your card, most of the time. Three parties sit between you and the answer, and knowing which one is saying no tells you who to ask.
- 1
The pharmacy benefit manager · CVS Caremark
This page is about the benefit manager itself. CVS Caremark builds the formularies, so what is preferred, excluded or subject to step therapy on them is its decision. Which of its formularies you get, and whether weight-loss drugs are on your plan at all, is your plan sponsor’s choice. Insurers we cover that run on CVS Caremark: Aetna, Molina Healthcare.
- 2
Your employer, if the plan comes through work
Weight-loss drugs are usually a category an employer buys or declines, not something the insurer includes by default. That is why two people holding identical cards get opposite answers, and why the useful question for member services is whether your plan includes the weight-loss medication benefit at all, before anything about criteria.
How prior authorization works here
Six steps. Specifics come from the criteria above; where CVS Caremark does not publish one, the step says what to ask for.
- 1
Confirm the benefit exists
Before any paperwork, ask member services whether your plan covers Mounjaro for weight management at all. A plan that excludes the category will refuse a perfect request.
- 2
Get the criteria in writing
Ask for the written prior authorization criteria for Mounjaro, so your prescriber answers the plan's questions rather than guessing at them.
- 3
Your prescriber documents the clinical picture
Current and baseline BMI, with dates. Conditions: Type 2 diabetes. Records of any diet, exercise or behavioral program.
- 4
Answer step therapy, if there is any
What the documents say: Metformin first, unless combination therapy is needed with A1C 7.5%+. If you already tried that drug, or cannot take it, the request should say so with dates.
- 5
Submit, then track it
Your prescriber sends the plan’s form with the notes. Write down the date and the reference number, and ask how you will hear back.
- 6
Plan for the renewal
What the documents say: Stable dose for 3+ months and a drop in A1C since starting.
Get your real answer
Sign in at Caremark.com and open Plan Summary under Plan & Benefits to check Mounjaro's tier and any step therapy. If you have type 2 diabetes, ask your prescriber to note your metformin history and A1C on the prior authorization.
Coverage is plan-specific: this page reports what CVS Caremark publishes, not a promise about your plan. Not medical or insurance advice.
