Coverage at a glance
| Indication | Coverage |
|---|---|
| Type 2 diabetes | Covered with prior authorization |
Plan type: Commercial non-Medicare. Each indication below lists the BMI and clinical thresholds, the prior-authorization documentation, and the published policy it comes from.
Coverage by indication
| Step therapy |
What the prior authorization needs:
- Documented type 2 diabetes diagnosis by at least one lab result: fasting glucose above 126 mg/dL, a 2-hour glucose tolerance test above 200 mg/dL, an A1C of 6.5% or higher, or a random plasma glucose of 200 mg/dL or higher with symptoms of hyperglycemia.
- Member is 18 years of age or older. Oscar approves ages 10 and up only for Bydureon BCise, Trulicity, and Victoza, not for Mounjaro.
- Step therapy: either an inability to use metformin or a failed trial of metformin at a minimum effective dose of 1,500 mg daily for at least 90 days, or a documented need for combination therapy with an A1C of 7.5% or higher.
- Initial approval lasts 12 months. Reauthorization requires evidence of response, such as a reduction in A1C since starting, maintenance of a target A1C below 7%, or improvement in fasting plasma glucose.
Policy PG152 (Ver. 4). Source: Oscar Clinical Guideline: Antidiabetic Agents - Glucagon-like Peptide-1 (GLP-1) Receptor Agonists (PG152, Ver. 4). payer_clinical_policy. Verified August 27, 2026.
What to do next
If you qualify under one of the covered indications above, prior authorization is the path. Match the documentation in the requirements list then have your prescriber submit it. Plans that approve reassess at renewal, so know your long-term maintenance dose before you start.
- Browse the prior-authorization letter library for a template that matches your plan and indication.
- Read the full coverage picture, denial reasons, and the four appeal pathways at GLP-1 insurance coverage.
- If the prior-authorization request is denied, the appeal letter library has templates by denial reason, covering peer-to-peer review, Level 1 and Level 2 internal appeal, and external review.
- If your plan does not cover the indication you need, compare cash prices in the cost guide or check whether a clinical trial near you fits. Neither one goes through your insurer. Clinical trials cost nothing and many pay you for your time. Some participants get a placebo, decided at random.
What it costs without insurance
The programs below bill you directly. Prices checked every Monday.
Frequently asked questions
Does Oscar cover Mounjaro?
Oscar covers Mounjaro for type 2 diabetes with prior authorization, and it sits on tier 2 of Oscar's 2026 formulary with a quantity limit of four pens every 28 days. Approval requires a documented type 2 diabetes diagnosis (for example an A1C of 6.5% or higher) plus either a failed 90-day trial of metformin at 1,500 mg daily or a documented need for combination therapy with an A1C of 7.5% or higher. Oscar does not cover Mounjaro for weight loss, because Mounjaro is FDA-approved for type 2 diabetes only. The weight-loss version of tirzepatide is Zepbound, which Oscar reviews under a separate weight-loss policy and which does not appear on this 2026 formulary. This reflects the published policy verified August 2026.
What does Oscar require to approve Mounjaro?
For type 2 diabetes: true
Coverage for other payers
See the full payer coverage index for every plan we have sourced.
How we built this page
Each page is built from a published payer policy document, government statute, or independent formulary analysis (KFF). Every indication row carries the source URL and the date we verified it. Where a payer's policy PDF was confirmed at its public URL but served as an unreadable binary, the policy number and coverage framework were cross-checked against secondary sources; those rows are marked lower confidence. Commercial coverage often depends on whether an employer elected the weight-management benefit. Those rows say varies by plan rather than a flat yes.
This is reference information, not medical or legal advice, and not a guarantee of coverage. GLP-1 coverage policies change often. Always confirm the current policy with your insurer using the number on your card before you rely on this page. If your experience differs from what is shown here, email hello@glpchart.com with the details and we will re-verify.
