Table of Contents
Introduction: Understanding Tirzepatide and Medicaid Coverage
Tirzepatide is a new type of medication that has become important in treating two major health conditions — type 2 diabetes and obesity. These conditions affect millions of people in the United States and often come with serious complications, such as heart disease, kidney problems, and nerve damage. Tirzepatide works differently from older diabetes or weight-loss medications because it acts on two hormone systems in the body — GLP-1 (glucagon-like peptide-1) and GIP (glucose-dependent insulinotropic polypeptide). These hormones help control blood sugar levels, appetite, and how the body uses energy. Because of this dual action, tirzepatide has shown stronger results in lowering blood sugar and supporting weight loss than many older treatments.
The U.S. Food and Drug Administration (FDA) first approved tirzepatide in 2022 under the brand name Mounjaro® for the treatment of adults with type 2 diabetes. In 2023, the same medication received approval under another brand name, Zepbound™, for chronic weight management in adults who have obesity or who are overweight with at least one related health condition such as high blood pressure or high cholesterol. These approvals have created new opportunities for people who have struggled to manage their diabetes or weight with older medications or lifestyle changes alone.
However, the cost of tirzepatide is a major concern for many patients. Without insurance, the medication can cost over $1,000 per month, making it unaffordable for most people. This is why insurance coverage, especially through Medicaid, is so important. Medicaid is a joint federal and state program that provides health coverage for people with low income, children, pregnant women, older adults, and individuals with disabilities. It helps pay for doctor visits, hospital stays, preventive care, and prescription drugs. Yet, what Medicaid covers can vary from one state to another, especially for newer or expensive medications like tirzepatide.
Understanding how Medicaid works is the first step toward getting coverage for tirzepatide. Unlike Medicare, which is run entirely by the federal government, Medicaid is managed by each state under federal guidelines. This means every state has its own rules about which drugs are covered, what documentation is required, and when a medication needs prior authorization — a review process that confirms a treatment is medically necessary. For example, one state’s Medicaid program may fully cover tirzepatide for diabetes, while another might still be reviewing whether to include it on its Preferred Drug List (PDL). Some states may cover it for weight management under Zepbound™, while others might only cover it for diabetes under Mounjaro®.
The approval process can feel confusing for patients and even for healthcare providers. Medicaid uses a combination of clinical guidelines and cost-effectiveness data to decide whether to include a new drug on its list of covered medications. Because tirzepatide is expensive and still relatively new, states are cautious in deciding how it will be covered. That means that many patients need to go through additional steps before their prescription is approved — such as submitting medical documentation, lab results, or proof that other medications have not worked.
This guide is designed to make that process easier to understand. It will walk you through the step-by-step process of how to get tirzepatide covered by Medicaid, including how to check if your state covers it, how to complete a prior authorization request, and what to do if your request is denied. It will also explain what information your doctor will need to provide, how long the process usually takes, and what options are available if you face a denial.
By learning how the system works, patients and healthcare providers can work together to improve the chances of approval. It is important to know that persistence and proper documentation are key. Medicaid programs are designed to cover treatments that are proven to be medically necessary. For patients with type 2 diabetes who cannot reach their blood sugar goals with other medications, or for those who meet the criteria for obesity treatment, tirzepatide can qualify as such a therapy when the right evidence is provided.
This article will not offer personal opinions or stories, but instead clear, factual information based on medical and policy guidelines. The goal is to help readers confidently navigate the steps required to access tirzepatide through Medicaid, no matter which state they live in. Understanding both the medication and the Medicaid approval system can save time, prevent unnecessary stress, and make it more likely that qualified patients receive the treatment they need.
In the sections that follow, we will look more closely at how tirzepatide works, who qualifies for it, how Medicaid decides which drugs to cover, and how to successfully apply for and maintain coverage. By the end of this guide, you should have a complete understanding of what to expect and how to take the right steps to get tirzepatide approved under your Medicaid plan.
What Is Tirzepatide and Who Qualifies for It?
Tirzepatide is a new kind of prescription medicine that helps people manage Type 2 diabetes and, more recently, obesity. It belongs to a group of medicines called GLP-1 and GIP receptor agonists. These medicines help the body control blood sugar and manage appetite. Tirzepatide is sold under two brand names made by Eli Lilly:
- Mounjaro®, which is approved to treat adults with Type 2 diabetes, and
- Zepbound™, which is approved for chronic weight management in adults with obesity or overweight who have certain health risks.
Even though both products contain the same active ingredient (tirzepatide), the approved uses are slightly different depending on which brand your doctor prescribes.
How Tirzepatide Works
Tirzepatide works by acting like two natural hormones in the body — GLP-1 (glucagon-like peptide-1) and GIP (glucose-dependent insulinotropic polypeptide). These hormones help regulate blood sugar after you eat. They also affect appetite and how your body stores fat.
Here’s how tirzepatide helps:
- Improves insulin response: It helps the pancreas release the right amount of insulin after meals.
- Reduces sugar production by the liver: It lowers the amount of glucose your liver makes.
- Slows digestion: It makes you feel full longer and reduces how quickly food leaves your stomach.
- Decreases appetite: It signals the brain to reduce hunger, helping with calorie control.
Because of these combined effects, tirzepatide can lead to lower blood sugar levels and significant weight loss when used with proper diet and exercise.
FDA Approvals and Medical Uses
Tirzepatide was first approved by the U.S. Food and Drug Administration (FDA) in 2022 under the brand name Mounjaro® to treat adults with Type 2 diabetes mellitus. This approval was based on several large clinical studies showing tirzepatide helped people achieve much better blood sugar control compared to older diabetes medications, such as insulin or semaglutide, when used alongside diet and exercise.
In late 2023, the FDA also approved tirzepatide under the brand name Zepbound™ for weight management in adults who are either:
- Obese (BMI of 30 or higher), or
- Overweight (BMI of 27 or higher) with at least one weight-related condition such as high blood pressure, high cholesterol, or Type 2 diabetes.
This second approval made tirzepatide one of the first medications to be officially approved for both diabetes and weight loss management, depending on the brand prescribed.
Who Qualifies for Tirzepatide
To qualify for tirzepatide, you must meet certain medical and diagnostic criteria. Medicaid and other insurance programs will usually require that these conditions are documented by a healthcare provider.
- For Type 2 Diabetes (Mounjaro®):
- The patient must be an adult (18 years or older).
- Must have a confirmed diagnosis of Type 2 diabetes (not Type 1 diabetes).
- Often, the patient should have tried at least one other diabetes medication (such as metformin or a sulfonylurea) without reaching target blood sugar goals.
- The patient must be working with their doctor on a diet and exercise plan to manage their diabetes.
- For Chronic Weight Management (Zepbound™):
- The patient must be an adult (18 years or older).
- Must meet one of the following:
- Body Mass Index (BMI) ≥30, or
- BMI ≥27 with at least one weight-related medical condition (for example, Type 2 diabetes, hypertension, or high cholesterol).
- Body Mass Index (BMI) ≥30, or
- The patient must also be enrolled in a comprehensive weight management program that includes a reduced-calorie diet and increased physical activity.
These eligibility rules are based on both FDA guidelines and typical Medicaid coverage requirements. However, specific Medicaid programs may have slightly different criteria depending on the state.
Why You Need a Prescription
Tirzepatide is only available by prescription. This is because it affects important hormone pathways and must be used under medical supervision. It’s given as a weekly injection under the skin, usually in the abdomen, thigh, or upper arm.
Your doctor will start you at a low dose and gradually increase it over several weeks. This helps your body adjust and reduces side effects such as nausea, diarrhea, or loss of appetite.
Before starting tirzepatide, your healthcare provider will:
- Review your medical history,
- Check for any contraindications (such as a personal or family history of certain thyroid tumors), and
- Explain how to safely use the injection pen.
If you qualify, your provider will then write a prescription and may help you start the Medicaid prior authorization process, which confirms your medical eligibility and ensures coverage for the medication.
Clinical Benefits and Safety
In clinical studies, tirzepatide has shown significant results:
- Many patients with Type 2 diabetes lowered their A1C levels to near-normal ranges.
- Participants in weight loss studies lost an average of 15–20% of their body weight over several months when combined with diet and exercise.
Common side effects include mild stomach upset, nausea, or diarrhea, which usually improve over time. Serious side effects are rare but can include pancreatitis or allergic reactions, which is why medical monitoring is important.
Tirzepatide is not recommended for people with Type 1 diabetes, a history of medullary thyroid carcinoma, or multiple endocrine neoplasia syndrome type 2 (MEN 2).
Tirzepatide is an advanced, dual-action medication that helps control blood sugar and support weight loss by mimicking two natural hormones. It is approved for adults with Type 2 diabetes (as Mounjaro®) and for weight management in adults with obesity or overweight (as Zepbound™).
To qualify, patients must meet clear medical criteria that depend on diagnosis, BMI, and prior treatments. Because tirzepatide is a prescription-only injectable medication, patients need regular check-ins with their doctor. When used properly and supported by a healthy lifestyle, tirzepatide can make a major difference in improving metabolic health and quality of life — especially when financial coverage through Medicaid makes it accessible.
How Does Medicaid Decide What Drugs It Covers?
Understanding how Medicaid decides which drugs it will pay for is an important step in getting tirzepatide covered. Medicaid is a health insurance program that helps millions of people in the United States, especially those with low income, disabilities, or special medical needs. While the program is funded by both the federal and state governments, each state runs its own version of Medicaid. This means that rules about which drugs are covered—and under what conditions—can vary a lot from one state to another.
How Medicaid Coverage Works
Medicaid covers many types of medical care, including doctor visits, hospital stays, and prescription drugs. However, not every medicine is automatically included. Each state has what is called a formulary or Preferred Drug List (PDL). This is a list of medications that the state Medicaid program has reviewed and agreed to cover.
A formulary is created to balance patient care with cost control. Since new medications, like tirzepatide, can be expensive, Medicaid reviews them carefully before adding them to the list. The goal is to make sure that a drug is both clinically effective and cost-effective—that is, that it works well for patients and provides good value for the public funds being used.
The Role of the Preferred Drug List (PDL)
The PDL is central to Medicaid’s prescription coverage decisions. A team of experts, often called a Pharmacy and Therapeutics (P&T) Committee, reviews new and existing medications. These experts may include doctors, pharmacists, and public health professionals. They study medical research, clinical trial data, and safety information about each drug.
When reviewing tirzepatide or similar medications, the committee asks questions such as:
- Does the drug work better than other medications already on the market?
- How safe is it for the intended patients?
- What are its possible side effects or risks?
- How much does it cost compared to similar treatments?
Based on these findings, the committee recommends whether the drug should be included in the PDL, and if so, under what conditions. Sometimes the drug is approved with restrictions, meaning that it may require prior authorization before Medicaid will pay for it.
Understanding Prior Authorization (PA)
Prior authorization (PA) is a process where the doctor must get permission from Medicaid before the patient can receive a particular medication. Medicaid uses PA to make sure that expensive or specialized drugs are prescribed only when medically necessary.
For tirzepatide, this usually means that the healthcare provider must submit paperwork proving that:
- The patient meets the clinical criteria (for example, has Type 2 diabetes or obesity).
- Other treatments, like metformin or lifestyle changes, have not worked well enough.
- The drug is being prescribed at an appropriate dose and for an approved use.
The state’s Medicaid office then reviews the request. If the documentation meets the requirements, the PA is approved, and the patient can get the medication covered. If not, the request may be denied, but an appeal can often be filed.
How States Make Their Decisions
Because Medicaid is run by individual states, each one develops its own process for evaluating and approving drugs. Some states automatically follow national recommendations, while others do independent reviews.
Key factors states consider include:
- Clinical Effectiveness: Does research show that the drug provides real health benefits?
- Safety Profile: What are the short- and long-term risks for patients?
- Cost Comparison: Is there a similar drug that works just as well but costs less?
- Population Needs: How many Medicaid patients could benefit from the drug?
- Budget Impact: How much will covering the medication cost the state’s Medicaid program?
A new medication like tirzepatide often goes through several stages of review. First, the state looks at data from the FDA and medical studies. Then, it may compare tirzepatide with other drugs in the same class, such as semaglutide. Finally, the P&T Committee or another review board votes on whether to list the medication on the state’s PDL.
If approved, the drug may be:
- Preferred: Automatically covered without extra paperwork.
- Non-preferred: Covered only if prior authorization is granted.
- Excluded: Not covered except under rare medical exceptions.
Differences Between Brand and Generic Drugs
Medicaid often prefers generic drugs because they cost less but usually work the same way as brand-name medications. However, tirzepatide is a brand-name medication made by Eli Lilly and does not yet have a generic version available. Because of this, states review it more carefully and often require prior authorization or proof that cheaper alternatives were tried first.
When a generic version eventually becomes available, coverage may expand, and the process may become easier for patients.
Why Policies Change Over Time
Drug coverage policies are not permanent. As new data, clinical studies, or cost information become available, states may update their formularies. For example, if tirzepatide proves to have strong long-term health benefits—like reducing diabetes complications or hospitalizations—more states may decide to add it to their preferred lists. Similarly, if the manufacturer offers price discounts or rebates, states may find it more affordable to cover.
Because of this, patients and healthcare providers should check their state’s Medicaid formulary every few months or contact the state Medicaid office for updates.
Medicaid coverage for medications like tirzepatide depends on a careful balance between medical need, safety, and cost. Each state decides based on expert review and available evidence. Understanding how this process works—especially how the PDL and prior authorization systems function—can help patients and providers better prepare their documentation and improve the chances of getting coverage approved.
Is Tirzepatide Covered by Medicaid in My State?
When someone is prescribed tirzepatide (brand names Mounjaro® for type 2 diabetes and Zepbound™ for weight management), one of the first questions they often ask is: “Will Medicaid pay for this?”
The answer depends on where you live. Medicaid coverage for medications, especially new ones like tirzepatide, varies from state to state because each state runs its own Medicaid program under federal guidelines.
How Medicaid Coverage Varies by State
Medicaid is funded by both the federal and state governments, but states have the power to decide which prescription drugs they include in their programs.
This means that while the federal government requires Medicaid to cover most essential medications, each state builds its own list of approved drugs called a Preferred Drug List (PDL) or formulary.
Some states quickly add new medications like tirzepatide after FDA approval, while others take months or even years to review them. States may also have different requirements before covering tirzepatide, such as:
- Only covering it for Type 2 diabetes (not weight loss).
- Requiring prior authorization (your doctor must explain why you need it).
- Asking for proof that you have tried and failed other medications first.
- Limiting coverage to people with specific BMI or blood sugar levels.
So, while one state might fully cover tirzepatide for eligible patients, another state might not cover it at all—or only under very strict rules.
How to Check If Your State Covers Tirzepatide
The most reliable way to find out if tirzepatide is covered by your Medicaid plan is to check your state’s official Medicaid website. Every state posts its Preferred Drug List (PDL) or formulary, which lists all drugs covered and any restrictions.
Here’s how you can do it step by step:
- Go to your state’s Medicaid website.
Type “Medicaid [your state name] PDL” or “Medicaid drug list [state name]” into Google.
Example: “Texas Medicaid PDL” or “Florida Medicaid drug list.” - Open the drug list or formulary.
These lists are often in PDF format and organized alphabetically by drug name. - Search for tirzepatide, Mounjaro, or Zepbound.
Use the search bar or “Ctrl + F” on your keyboard to find it quickly. - Check the coverage notes.
If it’s listed, there will usually be notes next to the drug. These might say things like “PA required” (prior authorization), “Non-preferred,” or “Covered for diabetes only.”- “PA required” means your doctor must send documentation before the medication will be approved.
- “Non-preferred” means the drug is available, but only if other cheaper drugs have been tried first.
- “Covered for diabetes only” means it’s approved for blood sugar control, not for weight management.
- “PA required” means your doctor must send documentation before the medication will be approved.
If you don’t see tirzepatide listed, it may mean that:
- It’s not yet on the state’s list (under review), or
- It may still be available through a special request or appeal process.
Examples of State Coverage (As of Recent Updates)
As of late 2024, several states have started covering tirzepatide for diabetes treatment through Medicaid, including:
- California
- New York
- Texas
- Illinois
- Florida
- Ohio
- Michigan
However, the specific rules differ.
For example:
- In some states, Mounjaro is covered for patients with Type 2 diabetes who have tried metformin or another GLP-1 drug and did not reach their blood sugar goals.
- In others, Zepbound for obesity treatment might not yet be covered because it was only recently approved for chronic weight management.
Because Medicaid policies are updated often, it’s important to check the latest version of your state’s PDL every few months.
How to Contact Your State’s Medicaid Office
If you can’t find the information online or it’s unclear, contact your state’s Medicaid customer service office directly. You can:
- Call the number listed on your Medicaid ID card.
- Ask to speak with someone about “pharmacy coverage or the Preferred Drug List.”
- Provide the medication name (Mounjaro or Zepbound) and ask,
“Is this drug covered under my plan, and what steps do I need to take to get approval?”
Customer service can tell you whether prior authorization is needed and can help direct your doctor to the correct forms.
What to Do If Tirzepatide Is Not Covered in Your State
If tirzepatide isn’t covered yet, you still have options:
- Ask your healthcare provider to submit a prior authorization or exception request.
Even if the drug isn’t listed, sometimes an exception can be made if your doctor provides strong medical justification. - Appeal a denial.
If Medicaid denies the request, you can appeal. This usually requires a letter from your doctor explaining why tirzepatide is medically necessary for your condition. - Recheck periodically.
States often review and update their formularies—sometimes quarterly. A drug that’s not covered now might be added later. - Look into manufacturer assistance programs.
Eli Lilly, the maker of tirzepatide, sometimes offers savings or assistance programs for patients who are uninsured or whose Medicaid plan doesn’t yet cover the drug.
Medicaid coverage for tirzepatide depends on where you live. Each state decides if and how it covers the medication, and the rules can change over time. Always check your state’s Preferred Drug List, talk with your doctor about prior authorization, and stay in contact with your Medicaid office.
What Documentation Is Needed to Get Tirzepatide Approved?
Getting tirzepatide (Mounjaro® or Zepbound™) covered by Medicaid usually requires proof that the medication is medically necessary. Medicaid programs use documentation to decide if a patient truly meets their rules for approval. Each state has its own forms and criteria, but the core documents and information are often the same. Preparing these papers carefully can make the difference between approval and denial. This section explains exactly what you’ll need, who completes each part, and why each document matters.
Doctor’s Prescription and Diagnosis Codes
The first document Medicaid needs is a prescription from your healthcare provider. This must include:
- The exact name of the medication (tirzepatide, Mounjaro®, or Zepbound™)
- The dose and frequency (for example, 5 mg once weekly)
- The diagnosis code that explains your medical condition
Diagnosis codes come from the ICD-10 system. These are short codes doctors use to describe your diagnosis in a way that insurance companies understand.
For example:
- E11.9 – Type 2 diabetes mellitus without complications
- E66.9 – Obesity, unspecified
Using the correct ICD-10 code helps Medicaid quickly identify that tirzepatide is being prescribed for a covered medical condition. If the code is missing or doesn’t match the approved diagnosis list, the request may be denied.
Proof of Medical History and Previous Treatments
Medicaid will also ask for evidence of your medical history. This shows that you and your doctor have already tried other reasonable treatments before starting tirzepatide.
This information can include:
- A record of past medications for diabetes or weight management (such as metformin, insulin, or lifestyle programs)
- The results of those treatments (for example, “A1C remained above target after six months of metformin”)
- Any side effects or reasons other treatments were stopped
This step is often called “step therapy” or “fail-first” documentation. Medicaid uses it to confirm that tirzepatide is not the first treatment you’ve tried. It also helps your provider show that switching to tirzepatide is a medically reasonable decision.
You can make this easier by bringing a list of your medications and your pharmacy records to your provider. This ensures that nothing is forgotten when completing the prior authorization form.
Supporting Lab Results and Measurements
Objective evidence supports your provider’s request. Medicaid reviewers often need lab results and physical measurements to see if tirzepatide fits your medical needs.
These may include:
- Hemoglobin A1C (HbA1c) results for people with diabetes
(shows average blood sugar control over 3 months) - Body Mass Index (BMI) for people seeking weight management treatment
(used to prove medical obesity; often coverage starts at BMI ≥ 30, or ≥ 27 with other conditions) - Weight history from medical visits
(to show that weight has remained stable or increased despite prior efforts) - Blood pressure and lipid levels if related to diabetes or metabolic health
Your healthcare provider should include copies of recent labs or clinical notes with the submission. Most Medicaid programs require that results be recent — usually within the past 6 months.
Documentation of Prior Treatments and Outcomes
In addition to medical history, Medicaid wants to see written evidence of treatment outcomes. This means showing what was tried before and what happened.
Examples of acceptable documentation include:
- A chart note from your doctor stating that you completed a lifestyle program but lost less than 5% of your weight.
- Records that you used metformin for six months but your HbA1c stayed above 7.5%.
- Notes explaining why another GLP-1 medication, such as semaglutide, was not tolerated or didn’t work.
If you stopped another medication because of side effects, make sure this is clearly written. For instance, “Patient discontinued due to persistent nausea.” Medicaid reviewers prefer detailed medical notes over simple statements like “ineffective.”
Your provider can include this documentation in an office visit note or attach it as a separate medical summary with the prior authorization request.
Prior Authorization Form (Completed and Signed)
Every Medicaid plan uses a Prior Authorization (PA) form for medications like tirzepatide. This form acts as the official request for coverage.
It usually includes:
- Patient information (name, Medicaid ID number, date of birth)
- Prescriber information (doctor’s name, contact, NPI number)
- Medication details (name, dose, quantity)
- Medical justification section (reason for use, diagnosis, previous medications)
- Signatures from the provider and sometimes the patient
It’s critical that the form is complete, legible, and accurate.
If any section is left blank, the request might be returned or denied. The provider’s office or clinic usually fills out and submits this form, but patients should ask for a copy for their records.
Importance of Accuracy and Consistency
Every piece of documentation must match across forms. The diagnosis code, medication name, and reason for therapy should be consistent between:
- The prescription
- The prior authorization form
- The doctor’s clinical notes
- The attached lab results
Even a small mismatch — such as “Zepbound 5 mg” on one document and “Mounjaro 5 mg” on another — can delay approval. Review all paperwork with your healthcare team before submission.
Role of the Prescribing Physician
The doctor or nurse practitioner prescribing tirzepatide plays a key role. They are responsible for:
- Writing the correct diagnosis
- Completing and signing the PA form
- Attaching medical notes and lab results
- Responding to Medicaid reviewers if clarification is needed
It helps to work with a provider familiar with Medicaid processes. If your provider is new to the system, the office’s billing or prior authorization specialist can help organize and send the documents properly.
How to Submit a Prior Authorization (PA) Request for Tirzepatide
Getting tirzepatide covered by Medicaid usually requires a process called prior authorization (PA). This step may seem complicated, but it is simply a way for Medicaid to confirm that the medicine is medically necessary for you. Every state’s Medicaid program uses prior authorization to manage expensive drugs and make sure they are used safely and correctly.
This section will walk you through everything you need to know about submitting a prior authorization for tirzepatide—what it is, who completes it, what forms and documents are needed, and how to avoid common mistakes that can delay approval.
What Is a Prior Authorization and Why It’s Needed
A prior authorization is a special request that your healthcare provider sends to your Medicaid plan before you can get a specific medication. It tells Medicaid why you need that drug and why other treatments might not work for you.
Tirzepatide, known by brand names Mounjaro® (for type 2 diabetes) and Zepbound™ (for obesity and weight management), is a newer and more costly medication. Because of this, Medicaid programs want detailed information before agreeing to pay for it. The goal is not to deny care, but to ensure the medicine is being prescribed for patients who meet the right medical criteria.
For example:
- Medicaid may want to see that you have type 2 diabetes or obesity diagnosed by your doctor.
- They may check that you have already tried other medicines or lifestyle changes that did not work well enough.
- They also want to confirm that the drug will be used under a doctor’s supervision and for the correct medical purpose.
Who Submits the Prior Authorization
The healthcare provider’s office—usually your doctor or clinic—submits the PA request to Medicaid. Patients do not fill out the form themselves, but they may need to provide some supporting information, like proof of Medicaid coverage or consent forms.
The request usually involves three parties:
- You (the patient) – You give your provider permission to apply on your behalf and supply medical history or insurance information.
- Your healthcare provider – They fill out the PA form, attach supporting medical records, and explain why tirzepatide is needed.
- Medicaid (or your managed care organization) – They review the request and decide if the medication will be covered.
If you are part of a Managed Care Organization (MCO) under Medicaid, your provider must send the PA request directly to that plan, not to the main state Medicaid office. Each plan has its own form and fax or online submission method.
Step-by-Step Process to Submit a Prior Authorization
Step 1: Get the Correct Form
Each state has its own Medicaid prior authorization form for tirzepatide. Sometimes, the form is specific to a medication class (for example, “GLP-1 receptor agonists”). Your provider can download the latest version from your state’s Medicaid website or from the Managed Care Plan portal. Using the wrong form can delay or deny your request.
Step 2: Fill Out the Form Completely
The form asks for:
- Patient information (name, date of birth, Medicaid ID number)
- Prescriber details (doctor’s name, NPI number, address, contact info)
- Medication information (tirzepatide dose, quantity, duration)
- Diagnosis and ICD-10 codes (for example, E11.9 for Type 2 diabetes)
- Clinical justification – why the medication is needed and what treatments have been tried before
- Lab results such as HbA1c, BMI, or weight records
Your doctor must clearly describe why tirzepatide is the best choice for you and attach supporting documents, such as medical notes or test results.
Step 3: Attach Supporting Documentation
Attach copies of:
- Lab results (A1C levels, weight, BMI)
- Progress notes showing previous treatments (like metformin, diet, or exercise programs)
- A letter of medical necessity written by your provider explaining why tirzepatide is required
Step 4: Submit the Form
The completed PA form and attachments can be submitted through:
- Fax: The most common method.
- Online portal: Many MCOs allow electronic submission for faster processing.
- Mail: Slower, but sometimes required if online or fax isn’t available.
Once submitted, your doctor’s office should keep copies and record the confirmation number or reference ID in case Medicaid requests more information later.
Step 5: Wait for Review
Medicaid will review your request and decide whether to approve or deny coverage. The typical review period is 5 to 14 business days, depending on the state. If more documentation is needed, they will contact your provider.
Common Reasons Prior Authorizations Are Denied
Understanding why PAs get denied can help prevent mistakes. Common reasons include:
- Missing or incomplete information on the form
- Wrong diagnosis codes or unclear justification
- No proof that other therapies were tried first
- Outdated or missing lab results
- Handwritten or illegible forms
If the PA is denied, Medicaid will send a denial notice explaining the reason and outlining how to appeal the decision. Your doctor can often correct the issue and resubmit quickly.
How to Avoid Delays
To speed up approval:
- Make sure your doctor uses the correct state or plan-specific PA form.
- Ensure all required fields are filled, with current lab results and diagnosis codes.
- Provide clear medical justification that matches Medicaid criteria.
- Ask your provider’s staff to confirm receipt by Medicaid or the managed care plan.
- Keep in touch with your doctor’s office to follow up on the review status.
It also helps if your healthcare provider includes supporting evidence from clinical guidelines, such as the American Diabetes Association (ADA) or the American Association of Clinical Endocrinology (AACE), showing that tirzepatide is appropriate for your diagnosis.
Submitting a prior authorization for tirzepatide is a detailed process, but when done carefully, it can lead to approval and full Medicaid coverage. The main keys are complete forms, clear documentation, and good communication between you, your provider, and the Medicaid office. By following these steps, you can reduce delays, avoid denials, and get access to the medication your doctor has prescribed for your health needs.
What to Do If Medicaid Denies Coverage
Getting a denial letter from Medicaid for tirzepatide can feel frustrating, especially if you and your doctor believe the medication is necessary. However, a denial does not always mean the end of the process. In many cases, people are approved after an appeal or resubmission. This section explains how to understand a denial, what steps to take next, and how to make your appeal stronger.
Understanding Why Medicaid Denies Coverage
Medicaid reviews every request for expensive medications like tirzepatide carefully. If something in your application does not meet their criteria, they can issue a denial. The denial letter will list one or more “reason codes.” These codes explain exactly why your request was not approved.
Common reasons for denial include:
- Incomplete or missing paperwork: The prior authorization (PA) form might not have all required fields filled out, or supporting documents may be missing.
- Lack of medical necessity documentation: Medicaid requires evidence that the medication is needed for your health. If your doctor did not include enough details, the request might be denied.
- Failure to meet coverage criteria: Each state’s Medicaid program has rules about who qualifies for tirzepatide. For example, some states approve it only for people with Type 2 diabetes, not obesity.
- Not enough proof of previous treatment attempts: Medicaid often wants to see that other treatments were tried first and did not work (for example, metformin or lifestyle changes).
- Non-preferred drug: In some states, tirzepatide may not be on the Preferred Drug List, meaning extra steps are needed to justify its use.
Understanding the exact reason for denial is the first step. Read the letter carefully, and if you’re unsure what it means, ask your doctor’s office, pharmacist, or Medicaid representative to explain it in simple terms.
Step 1: Review the Denial Reason Carefully
Take a close look at the letter or email from Medicaid. It should tell you:
- The date the decision was made.
- The specific reason for denial.
- Instructions on how to appeal and the deadline for doing so.
You usually have a limited time to appeal, often between 30 and 60 days from the date of the denial notice. Missing this deadline could mean you have to start over. Mark the deadline on a calendar right away.
Step 2: Gather Supporting Medical Documentation
The next step is to strengthen your case. Work with your healthcare provider to collect all the information Medicaid needs to reconsider the decision. This may include:
- Medical records showing your diagnosis (for example, Type 2 diabetes or obesity with BMI over 30).
- Lab results that demonstrate your current health status (such as HbA1c, fasting glucose, or weight history).
- Records of past treatments, including medications or programs that were tried before tirzepatide and why they were not effective or caused side effects.
- Physician’s statement of medical necessity, explaining why tirzepatide is important for your care. This letter should be short, clear, and focused on medical facts.
Make sure everything is accurate and up-to-date before you resubmit. Incomplete documentation is one of the most common reasons for denial.
Step 3: Write and Submit an Appeal Letter
An appeal is a formal request asking Medicaid to review their decision again. Most states have an appeal form that must be filled out, but you can also include a cover letter from you or your doctor.
A strong appeal letter should include:
- Your identifying information — name, Medicaid ID number, and date of birth.
- Reference to the denial — include the denial date and case number.
- A clear explanation — why you disagree with the decision.
- Supporting medical details — summarize your condition, previous treatments, and the medical need for tirzepatide.
- Attachments — include copies of medical records, doctor’s notes, and lab results.
Keep your tone polite and factual. The goal is to show why tirzepatide is necessary, not to express frustration.
Submit your appeal exactly as instructed in the denial letter — some Medicaid offices require mail or fax submissions, while others accept electronic uploads. Keep a copy of everything you send.
Step 4: Resubmit Within the Time Limit
Timing is critical. Every state has its own rules, but most allow 30 to 45 days to file an appeal. Late submissions are often rejected automatically. If your doctor or clinic is helping you, make sure they know the deadline and confirm the appeal has been sent.
Once Medicaid receives the appeal, they will send a confirmation. Keep that letter for your records. If you don’t get confirmation within a week or two, call your state’s Medicaid office to verify receipt.
Step 5: Strengthen Your Case With Medical Support
Your provider can help by submitting a more detailed letter of medical necessity or participating in a peer-to-peer review if available. A peer-to-peer review is a conversation between your doctor and a Medicaid medical reviewer. This allows your doctor to explain why tirzepatide is the best option for you based on your specific medical history.
When possible, your doctor can also cite official guidelines, such as those from:
- The American Diabetes Association (ADA) for Type 2 diabetes management.
- The American Association of Clinical Endocrinology (AACE) for obesity treatment.
Including these references shows that tirzepatide use follows current medical standards.
Step 6: Follow Up and Stay Informed
After submitting the appeal, it may take two to six weeks for Medicaid to make a new decision. During that time:
- Call your Medicaid office or managed care plan every week or two to ask for updates.
- Keep all communication records, including dates, names, and reference numbers.
- If the appeal is still denied, ask about additional appeal levels. Some states allow a second-level appeal or an independent medical review.
A Medicaid denial for tirzepatide does not mean the process is over. Denials are common but can often be overturned when you and your doctor provide more detailed documentation and clear medical reasoning. Stay calm, stay organized, and follow the steps carefully. With persistence and proper support, many patients are eventually approved for tirzepatide coverage through Medicaid.
How to Work With Your Healthcare Provider for Approval
Getting tirzepatide covered by Medicaid can be a complex process, but working closely with your healthcare provider makes it much easier. Medicaid often requires strong documentation to prove that a medication is medically necessary, and your provider’s role is critical in preparing that proof. This section explains how to partner effectively with your doctor, nurse practitioner, or pharmacist to increase your chances of approval.
Why Your Provider’s Support Matters
Medicaid will only approve expensive drugs like tirzepatide when the prescribing provider clearly shows that it is medically necessary. Your doctor’s knowledge of your medical history, previous treatments, and lab results is what Medicaid reviewers rely on to make their decision.
Doctors and other licensed prescribers must submit the prior authorization (PA) request, not patients. This form requires clinical details such as your diagnosis, past medications that did not work, your A1C level if you have diabetes, and your body mass index (BMI) if the drug is prescribed for weight management. A provider who understands this process can help you avoid missing information that might lead to a denial.
The more complete and well-documented your provider’s submission is, the more likely Medicaid is to approve your request the first time.
How Providers Can Advocate for You
An experienced provider can be your advocate by presenting your case clearly and professionally. Advocacy means going beyond just filling out forms — it includes explaining why tirzepatide is the right treatment for you based on medical evidence.
Here’s how providers can help:
- Use clear diagnostic codes: Your doctor should use the correct ICD-10 code for your condition. For example, E11.9 for Type 2 diabetes or Z68.3 for BMI-related obesity.
- Describe failed past treatments: Medicaid wants to know if other drugs, such as metformin or lifestyle changes, were tried and did not lead to success. Your provider should note these details clearly.
- Provide measurable results: Including lab results, A1C readings, weight trends, and progress notes can strengthen the request.
- Attach clinical justification: Providers can include short explanations that cite medical guidelines or scientific studies showing why tirzepatide is appropriate for your case.
When providers frame the request around clinical evidence and medical necessity, Medicaid reviewers can see that the drug is not a luxury but a necessary part of treatment.
Importance of Clear Medical Documentation
In Medicaid reviews, documentation is everything. Missing or vague information can delay the process or cause a denial. The provider’s notes should:
- Match the diagnosis listed on the prior authorization form.
- Include recent progress notes (within the last 6–12 months).
- Explain the patient’s symptoms and how they impact daily life.
- Show how other medications or treatments were not effective or caused side effects.
Strong documentation paints a clear picture of why tirzepatide is needed. For example:
“Patient has Type 2 diabetes with uncontrolled blood sugar despite metformin and dietary management. Most recent A1C = 8.9%. BMI = 36 kg/m². Tirzepatide is requested to improve glycemic control and assist with weight management.”
Such detail helps reviewers understand the patient’s condition without guessing.
Using Evidence-Based Guidelines
Medicaid reviewers often compare requests to national medical guidelines, such as those from:
- The American Diabetes Association (ADA)
- The American Association of Clinical Endocrinology (AACE)
- The Obesity Society
When your provider references these standards, it shows that the treatment follows accepted medical practice. For example, the ADA recommends considering GLP-1 receptor agonists like tirzepatide for patients who have not reached glucose goals with first-line therapy. Including that reference in the prior authorization supports your provider’s request and makes it easier for Medicaid to approve.
The Role of Pharmacists in the Process
Pharmacists are also valuable partners. They understand both the clinical and insurance sides of the process. A pharmacist can:
- Check whether tirzepatide is on your state’s Medicaid Preferred Drug List (PDL).
- Help ensure that dosage and instructions on the prescription match Medicaid requirements.
- Follow up with the prescriber or Medicaid if extra documentation is needed.
- Advise on appeals if the initial request is denied.
Pharmacists often have direct contact with Medicaid pharmacy benefit managers (PBMs), making them an excellent bridge between patients and insurers.
How to Request a Peer-to-Peer Review
If Medicaid denies the request even after a detailed prior authorization, your provider can request a peer-to-peer review. This means your doctor speaks directly with another doctor (often hired by Medicaid) to explain why the medication is necessary.
During this call, the provider can:
- Clarify any unclear details in the documentation.
- Emphasize failed treatment history and patient risks.
- Reference guidelines or lab results in real time.
Peer-to-peer reviews can often overturn denials when communication on paper wasn’t enough.
Communicating and Following Up
Good communication between you and your healthcare team is essential.
Here’s how to stay involved:
- Ask your doctor’s office when they plan to submit the prior authorization.
- Follow up within 5–10 business days to check on the status.
- Keep copies of any letters or forms you receive from Medicaid.
- Notify your provider if you receive a denial or request for more information.
Being proactive helps keep your case moving and shows both Medicaid and your care team that you are serious about your treatment.
Working with your healthcare provider is the most important factor in getting tirzepatide approved by Medicaid. Providers know the medical details and language Medicaid reviewers understand. When you and your provider communicate well, use solid evidence, and provide complete documentation, you significantly increase the chance of a successful approval.
How Long Does the Medicaid Approval Process Take?
Getting tirzepatide covered by Medicaid can take time. Each state has its own review rules and approval steps, so there is no single national timeline. Still, most people can expect the full process—from sending the first prior authorization form to getting a final decision—to take a few days to several weeks. The total time depends on how complete the paperwork is, how quickly the doctor and pharmacy respond to requests, and whether the first request is approved or denied. This section explains each stage, what causes delays, and how you can keep the process moving.
Typical Review Time for the First Prior Authorization
After your doctor sends the prior authorization (PA) form to your Medicaid plan, the plan reviews it to decide if tirzepatide is “medically necessary.”
- Most Medicaid programs respond within 5–14 business days.
- Some states decide even faster, within 72 hours, if the request is marked “urgent.”
- Other plans may take longer—up to 21 days—if they need extra medical records or if the request goes through a managed-care organization instead of the state directly.
- Some states decide even faster, within 72 hours, if the request is marked “urgent.”
- What the reviewers check:
- That your doctor used the correct form and filled in every section.
- That the diagnosis code (for example, E11.9 for Type 2 diabetes) matches the reason tirzepatide is being prescribed.
- That lab values such as A1C or BMI meet the program’s medical policy.
- That you have tried standard medications (like metformin or lifestyle therapy) first, if the policy requires it.
- That your doctor used the correct form and filled in every section.
If everything looks right, the plan issues an approval notice to the doctor and pharmacy. The pharmacy can then fill the prescription, and you may owe only a small copay, depending on your state’s rules.
Why Some Requests Take Longer
Even a small mistake can slow down the review. Here are common reasons delays happen:
- Missing or incomplete information: The plan cannot process the request if lab results, weight history, or treatment notes are missing.
- Wrong form or coding errors: Each Medicaid plan has its own PA form. Using the wrong one or putting the wrong ICD-10 code can restart the process.
- Additional documentation requests: Sometimes reviewers send a “request for more information.” The clock stops until your doctor answers.
- High volume: Around the start of the year or after new drug approvals, Medicaid offices get more PAs, which can stretch response times.
- Communication gaps: The doctor’s office, pharmacy, and Medicaid plan may not share updates quickly, leaving the patient unsure of progress.
Patients can help by asking their doctor’s staff to confirm that all forms and records were sent on the same day. It also helps to write down the date the form was submitted so you can follow up if you don’t hear back.
What Happens After an Approval
Once approved, the pharmacy receives confirmation electronically.
- The approval letter lists the start and end date of coverage, often 6 to 12 months.
- Before the approval expires, your doctor will need to submit a renewal authorization with updated information (like new weight or A1C results) to keep coverage active.
- Refill delays can happen if the renewal is late, so mark your calendar to remind your doctor’s office a few weeks before the end date.
If the Request Is Denied
If Medicaid denies the PA, the letter must state the reason. Common reasons include:
- “Did not meet medical necessity criteria.”
- “Insufficient documentation.”
- “Alternative therapies not yet tried.”
You and your doctor have the right to appeal. The appeal process usually takes longer than the first review—often 30 to 45 days—because a different reviewer or committee examines the case again. If you request a peer-to-peer review, your doctor can speak directly with another clinician at the Medicaid plan to explain why tirzepatide is needed.
How to Track Your Request
Staying informed helps prevent long delays.
- Ask for a reference number: When your doctor’s office sends the PA, they receive a confirmation or case ID. Write it down.
- Call or check online: Many Medicaid plans let patients or providers check PA status through an online portal or phone hotline.
- Stay in contact with the pharmacy: Pharmacists often see approval updates first. Ask them to notify you when the claim changes from “pending” to “paid.”
- Follow up regularly: If more than two weeks pass with no update, contact your doctor’s office to confirm whether the plan requested more documents.
Factors That Influence Overall Timing
Several things can shorten or lengthen the timeline:
- Completeness of paperwork – Full medical notes and correct codes speed up approval.
- State policies – Some states fast-track diabetes drugs; others require two failed therapies first.
- Doctor responsiveness – The faster the doctor replies to questions from Medicaid, the faster approval happens.
- Appeal complexity – Simple clerical errors can be fixed in days; full medical appeals can take weeks or even months.
- Communication between parties – Frequent updates between the patient, provider, and pharmacy reduce confusion.
If everything is correct the first time, Medicaid may approve tirzepatide in about one to two weeks. If there are questions or missing records, expect three to six weeks. If you must appeal, the total time may reach six to eight weeks before a final answer arrives. While that can feel long, knowing what each step involves can reduce stress and help you plan ahead.
Always keep copies of your forms, stay in contact with your healthcare team, and don’t hesitate to ask for updates. Careful organization and clear communication are the best ways to make sure your tirzepatide coverage moves forward as smoothly and quickly as possible.
Tips for Improving Your Chances of Approval
Getting tirzepatide (brand names Mounjaro® and Zepbound™) covered by Medicaid can feel like a complicated process. Each state has its own rules, and Medicaid often asks for extra paperwork before approving new or expensive medications. However, you can improve your chances of success by being careful, organized, and working closely with your healthcare team. The following steps explain how to make your application stronger and reduce the chances of being denied.
Make Sure All Documentation Is Complete and Accurate
Incomplete or incorrect paperwork is one of the most common reasons Medicaid denies medication coverage. Every detail matters. Your doctor or clinic must include all the required information on the prior authorization (PA) form. This includes:
- Your full name, Medicaid ID number, and date of birth.
- The exact name and dose of tirzepatide your doctor is prescribing.
- The diagnosis code (ICD-10) — for example, E11.9 for Type 2 diabetes or E66.9 for obesity.
- Recent lab results that support the diagnosis (for example, HbA1c level, BMI, or weight history).
- Notes showing that you tried other treatments first and they were not successful.
Ask your doctor’s office to double-check that all fields are filled in, signed, and dated before submitting. Small errors, such as missing a signature or an incorrect diagnosis code, can delay approval or lead to an automatic denial. Having clean, organized paperwork from the start saves time and helps Medicaid reviewers quickly see that the request meets their rules.
Include Strong Clinical Justification
Medicaid reviewers want to see clear medical reasons why tirzepatide is needed. This is called clinical justification. Your doctor should explain, in simple terms, why this medicine is the best option for your specific condition. Strong justification might include:
- Your medical history showing you tried other medicines like metformin or lifestyle programs without enough success.
- Specific health goals, such as lowering A1c levels or reducing cardiovascular risk.
- Documented complications of diabetes or obesity, such as high blood pressure, fatty liver, or nerve pain, that may improve with tirzepatide.
- References to clinical guidelines from trusted medical organizations, such as the American Diabetes Association (ADA) or the American Association of Clinical Endocrinology (AACE).
When your doctor provides medical evidence, it helps Medicaid understand that the request is not just for convenience — it’s medically necessary. Including brief, clear statements like “Patient has Type 2 diabetes uncontrolled on metformin and needs tirzepatide to reach goal A1c <7%” can make a big difference.
Use Supporting Evidence and Guidelines
Medicaid decisions are guided by evidence-based medicine. Your provider can refer to official guidelines or published studies showing the benefits of tirzepatide. For example, the ADA Standards of Care support the use of GLP-1 receptor agonists for patients who need additional glucose control or weight management. Quoting these guidelines in the prior authorization form gives your application more weight.
If your doctor can show that your medical situation matches what these guidelines recommend, Medicaid reviewers are more likely to approve coverage. Supporting data such as improved blood sugar control, weight reduction, or decreased cardiovascular risk can also be included in the form or a separate letter.
Keep Good Communication Between All Parties
Clear communication between your doctor, pharmacy, and Medicaid office can prevent long delays. After your doctor submits the prior authorization, follow up regularly. Ask your doctor’s office when they sent the request and confirm that Medicaid received it.
You can also contact your Medicaid plan’s pharmacy benefit manager (PBM) to ask about the status of your case. Many states provide online portals where you can check if your medication is pending, approved, or denied. If something is missing — for example, a lab report or a form — fix it quickly. Prompt communication ensures that your application moves forward instead of sitting in review for weeks.
It can also help to ask your pharmacy to alert you if the PA is denied or delayed. Sometimes the pharmacy learns about the decision before the doctor’s office does.
Be Persistent and Stay Organized
Getting coverage may take time, and some patients are approved only after an appeal. Do not give up if you get a denial letter. Review the reason carefully and ask your doctor to submit an appeal with additional information. Persistence pays off. Many people receive approval after providing stronger documentation or updated lab results.
Keep a record of all paperwork, dates, and phone calls. Write down when your doctor submitted the prior authorization, when you called Medicaid, and what was said. Having this information helps you stay on top of deadlines and provides proof if you need to appeal.
Work as a Team With Your Healthcare Provider
You are not alone in this process. Your healthcare provider has experience dealing with insurance paperwork and can advocate for you. Ask your provider to write a short “letter of medical necessity” if your case is complicated or if Medicaid has denied the medication before.
A strong letter from your provider can highlight how tirzepatide is expected to improve your condition and reduce future healthcare costs — something Medicaid programs consider when making decisions. Many clinics also have staff who specialize in prior authorizations. Don’t hesitate to ask for their help.
Follow Up and Update Your Information
Sometimes approval depends on having the most recent information. If your health changes — for example, your A1c rises or your weight increases — let your doctor know so they can update your records before resubmitting. This updated information can show Medicaid that your condition is worsening and that the medication is medically necessary.
Also, check that your Medicaid eligibility is current and that your contact information is correct. Missed mail or outdated records can cause unnecessary delays.
Improving your chances of Medicaid approval for tirzepatide takes preparation, communication, and persistence. Start by ensuring your paperwork is complete and accurate. Work closely with your healthcare provider to explain medical necessity clearly and provide supporting evidence. Keep all records, follow up often, and don’t give up if the first request is denied.
Resources for Patients and Providers
Getting tirzepatide (brand names Mounjaro® and Zepbound™) covered by Medicaid can feel complicated, but you are not alone. There are several trusted resources that patients, caregivers, and healthcare providers can use to make the process smoother. This section lists reliable tools, websites, and contact points that can help you check coverage, fill out forms, appeal denials, and find financial support if needed. Each type of resource below plays an important role in getting the medication approved and covered.
State Medicaid Formularies and Preferred Drug Lists (PDLs)
Every state manages its own Medicaid program. This means that drug coverage rules are not the same everywhere. To see if tirzepatide is covered in your state, you can look at your state’s Preferred Drug List (PDL) or formulary.
A PDL is a list of medicines that Medicaid will pay for, along with any restrictions such as prior authorization or step therapy requirements. These lists are usually updated every few months.
You can find your state’s Medicaid PDL by:
- Visiting your state Medicaid website (for example, “Texas Medicaid PDL” or “Florida Medicaid Formulary”).
- Searching for a section called “Prescription Drug Coverage” or “Pharmacy Benefits.”
- Calling your state Medicaid customer service number, which is usually listed on your insurance card.
When checking the list, look under both Mounjaro® (for diabetes) and Zepbound™ (for obesity or weight management). If the medication has a note like “PA required,” that means you will need to complete a Prior Authorization form before Medicaid approves it.
If you cannot find tirzepatide on your state’s list, it might still be available under managed care plans. Some states allow separate plans to manage their own formularies. Your doctor’s office or pharmacist can confirm which list applies to you.
Downloadable Prior Authorization (PA) Forms and Appeal Templates
To get coverage for tirzepatide, your doctor will often need to fill out a Prior Authorization (PA) request. This form provides medical proof that the medication is needed and explains why other treatments did not work.
You can find your state’s PA form:
- On your state Medicaid website under the “Pharmacy” or “Providers” section.
- By asking your healthcare provider’s office or pharmacist.
- Through managed care organizations (like Molina, Amerigroup, or UnitedHealthcare Community Plan) that administer Medicaid in some states.
These forms usually ask for:
- The patient’s diagnosis (like Type 2 Diabetes or Obesity).
- Current medications and prior treatments.
- Lab values such as HbA1c or BMI.
- The prescriber’s notes supporting the need for tirzepatide.
If coverage is denied, you or your doctor can use an appeal template to request a review. Many advocacy groups and state Medicaid websites provide sample appeal letters. These letters help you explain why tirzepatide is medically necessary. Always include medical records, lab results, and your provider’s statement with the appeal.
Official Manufacturer Support from Eli Lilly
Eli Lilly, the manufacturer of Mounjaro® and Zepbound™, offers several assistance programs to help patients access medication. These programs can support patients while waiting for insurance approval or if Medicaid denies coverage.
Eli Lilly Patient Assistance Program (PAP):
- Provides free or discounted medication to patients who qualify based on income.
- Applications can be completed online or printed from the official Lilly Cares website.
- You will need proof of income, a prescription from your healthcare provider, and details about your Medicaid status.
Mounjaro and Zepbound Support Pages:
- Contain downloadable resources such as doctor discussion guides, savings card information (for non-Medicaid patients), and instructions for getting started.
- Offer phone and chat support for coverage questions.
While savings cards usually cannot be used with Medicaid, the support staff can still help guide patients through the prior authorization or appeal process.
Contact Information for Medicaid Offices
If you have questions about your coverage, it is often best to contact your state’s Medicaid office directly. The office can confirm whether tirzepatide is covered and explain what steps you need to take.
You can find your state’s contact information at:
https://www.medicaid.gov/about-us/contact-us/contact-state-page.html
When calling, have these items ready:
- Your Medicaid ID number.
- Your full name and date of birth.
- The name of your healthcare provider or pharmacy.
- The name of the medication (tirzepatide, Mounjaro, or Zepbound).
Ask specifically:
- “Is tirzepatide covered under my plan?”
- “Does it require prior authorization?”
- “What form does my doctor need to complete?”
Keep notes from your call, including the name of the person you spoke with and the date, so you can refer to them later if needed.
Patient Support and Advocacy Resources
There are nonprofit and government organizations that help patients navigate complex insurance or medication access issues. These include:
- Patient Advocate Foundation (PAF) – Offers case management services and appeal support for patients denied coverage.
- NeedyMeds.org – Lists medication assistance programs and discount resources.
- American Diabetes Association (ADA) and Obesity Action Coalition (OAC) – Provide educational materials and links to insurance coverage resources.
These organizations cannot guarantee approval, but they can help you understand your rights and options under Medicaid.
Working Together as a Care Team
The best results often come when patients, providers, and pharmacists work together. Providers can ensure medical forms are complete, pharmacists can confirm formulary details, and patients can follow up with Medicaid to check progress. This teamwork shortens delays and improves the chance of getting approval.
By using the resources listed above — state formularies, prior authorization forms, manufacturer programs, Medicaid offices, and patient advocacy groups — both patients and providers can navigate the Medicaid system more confidently. Staying organized, asking questions, and using official tools can make a major difference in getting tirzepatide approved and covered. Remember: every state has its own rules, but with the right information and persistence, access is possible.
Conclusion: Navigating Medicaid Coverage for Tirzepatide
Getting tirzepatide covered by Medicaid can seem confusing at first, but it becomes much easier once you understand how the process works and what steps to take. This medication, approved to help manage Type 2 diabetes and obesity, can be life-changing for many people. However, because of its high cost and recent approval, Medicaid coverage may not be automatic in every state. This is why patients and healthcare providers need to work closely together to follow the right steps for approval.
The first and most important step is to check your state’s Medicaid formulary—the official list of drugs that are covered. Medicaid programs are run by individual states, and each state has its own rules. Some states cover tirzepatide for both diabetes and obesity, while others only approve it for diabetes or require strong medical documentation. By looking up your state’s Preferred Drug List (PDL) online or contacting your Medicaid office, you can find out if tirzepatide is covered and under what conditions. This information helps you and your doctor prepare the correct paperwork from the beginning, which can save a lot of time.
Once you confirm that your state covers tirzepatide, the next step is to submit a prior authorization (PA). A prior authorization is a request your doctor sends to Medicaid that explains why you need this specific medication. It is not enough to have a prescription; Medicaid usually requires proof that tirzepatide is medically necessary. For example, your doctor may need to show that you have already tried other diabetes medications without enough improvement or that your current treatment is not controlling your blood sugar levels. If you are using tirzepatide for weight management, your doctor will likely need to include your BMI, past weight-loss attempts, and any related health problems such as high blood pressure or sleep apnea.
It is important that the PA form is complete and detailed. Missing information is one of the main reasons Medicaid denies requests. Make sure the form includes your diagnosis codes (like Type 2 diabetes: E11.9 or obesity: E66.9), recent lab results, and medical notes showing your progress or challenges with other treatments. Clear documentation tells Medicaid reviewers that the request is justified.
If your PA is denied, do not lose hope. Many patients are approved after appealing. A denial does not mean you cannot get coverage—it usually means Medicaid needs more information. Read the denial letter carefully to understand the reason. Then, with your doctor’s help, you can prepare an appeal that includes additional evidence or explanations. For instance, your provider might write a short letter explaining why tirzepatide is necessary for your condition and how other medications failed to control it. Some states allow a second-level appeal if the first one is denied, so persistence can make a difference.
Working closely with your healthcare team is one of the most effective ways to increase your chances of success. Your doctor, pharmacist, and sometimes even a nurse case manager can help you track your request and respond quickly if Medicaid asks for more information. Pharmacists can also play an important role—they often know how to navigate insurance requirements and can check whether the PA was submitted correctly or if it is still pending. Maintaining communication with your healthcare team ensures that small issues, like missing lab results or outdated forms, do not delay approval.
It is also helpful to understand the timeline. Most Medicaid programs respond to PA requests within 5 to 14 business days. If you need to appeal, the process may take another 30 to 45 days. Although this can feel slow, knowing the average waiting period helps set realistic expectations and prevents unnecessary stress. During this time, stay in touch with your doctor’s office or the Medicaid pharmacy line to confirm that the request is moving forward.
Success often depends on persistence and organization. Patients who follow up regularly, provide complete paperwork, and stay informed about their state’s coverage rules are much more likely to get approval. Keeping copies of all forms, letters, and emails can also help if you need to appeal or if Medicaid changes its coverage policies later on.
In addition to Medicaid, some patients may qualify for manufacturer assistance programs through Eli Lilly, the company that makes tirzepatide. These programs can sometimes offer temporary support while coverage is being decided. Checking these resources early can help bridge the gap if there is a delay in approval.
As more states update their policies and as tirzepatide becomes more widely used, Medicaid coverage is likely to expand. Staying updated with official Medicaid websites or your state’s Department of Health announcements ensures you don’t miss important changes. Policies can shift quickly—what is not covered today might be added to the formulary next month.
In the end, navigating Medicaid coverage for tirzepatide is a process that requires patience, documentation, and teamwork. By verifying your state’s coverage, submitting a thorough prior authorization, and appealing if necessary, you give yourself the best chance of success. Remember that every approval begins with accurate information and persistence. With the right preparation and support, you can gain access to the medication you need to manage your health and improve your quality of life.
Research Citations
Williams, E., Rudowitz, R., & Bell, C. (2024, November 4). Medicaid coverage of and spending on GLP-1s. KFF.
Liu, B. Y., & Rome, B. N. (2024, March 14). State coverage and reimbursement of antiobesity medications in Medicaid. JAMA, 331(14), 1230–1232.
Washington State Health Care Authority. (2025, May 1). GLP-1 receptor agonists—Zepbound (tirzepatide): Clinical policy (Apple Health/Medicaid).
MassHealth. (2024, October 1). MassHealth Pharmacy Facts—Issue 3: MassHealth coverage of weight loss drugs (Zepbound update).
MassHealth. (2025, August 15). Pharmacy Facts #252: Change to the management of Zepbound (tirzepatide) for MassHealth patients with diabetes and overweight or obesity.
Louisiana Medicaid. (2025, June). Tirzepatide (Zepbound): Prior authorization and treatment agreement requirements.
North Carolina Department of Health and Human Services, NC Medicaid. (2025, September 5). NC Medicaid to change coverage for GLP-1 weight-management medications.
Institute for Clinical and Economic Review. (2025, April 9). Affordable access to GLP-1 obesity medications: Strategies to guide market action and policy solutions.
Christensen, K., Lee, T., Dollear, T., Inneh, A., & Patel, U. (2025). Medicaid state-level cost impact of GLP-1 coverage for obesity. American Journal of Preventive Medicine. Advance online publication.
Aetna Better Health (Medicaid). (2025). Coverage policy/guideline: Zepbound (tirzepatide) (Effective March 10, 2025; Last review Jan 24, 2025).
Questions and Answers: Tirzepatide with Medicaid
Tirzepatide is a GIP/GLP-1 receptor agonist. It’s sold as Mounjaro for type 2 diabetes and Zepbound for chronic weight management.
Yes. State Medicaid programs must cover outpatient drugs from participating manufacturers for medically accepted indications, and they have to cover GLP-1 formulations used to treat type 2 diabetes, including Mounjaro.
It’s optional and varies by state. As of August 2024, only 13 states covered GLP-1s for obesity treatment, and more states are considering coverage.
Utilization controls are common. Most covering states use prior authorization and BMI requirements aligned with the FDA label, such as BMI of 30 or higher, or 27 with a weight-related condition.
Mounjaro is for type 2 diabetes and is covered when medically necessary. Zepbound is for weight management, and coverage is state-optional and typically prior-authorization restricted.
Medicaid cost-sharing is limited to nominal amounts, and total cost-sharing is capped—generally no more than 5% of family income. Actual copays vary by state.
Very likely. States frequently require prior authorization for GLP-1 or dual-agonist drugs. It’s a standard Medicaid tool to manage pharmacy benefits.
The amount, duration, and scope must be consistent with the state’s fee-for-service coverage, but managed care organizations may apply different prior-authorization rules or medical-necessity criteria unless the state specifies otherwise.
No. The FDA warns against unapproved or compounded GLP-1 products sold online. Medicaid coverage applies only to FDA-approved drugs dispensed through legitimate pharmacies.
You can review your state Medicaid preferred drug list or formulary and prior-authorization criteria on the state’s Medicaid pharmacy page, or contact your Medicaid plan for details.
Dr. Melissa VanSickle
Dr. Melissa Vansickle, MD is a family medicine specialist in Onsted, MI and has over 24 years of experience in the medical field. She graduated from University of Michigan Medical School in 1998. She is affiliated with medical facilities Henry Ford Allegiance Health and Promedica Charles And Virginia Hickman Hospital. Her subspecialties include General Family Medicine, Urgent Care, Complementary and Integrative Medicine in Rural Health.