Please see additional formulary plan information below

*Represents Commercial and Medicare Formulary data

Source: Managed Markets Insight & Technology (MMIT), LLC as of 4/30/2026, and is subject to change without notice by a health plan or state. Please contact the plan or state for the most current information. This information is not a guarantee of coverage or payment (partial or full). Actual benefits are determined by each plan administrator in accordance with its respective policy and procedures. Employers and employer groups may also offer additional benefit designs which may be different than described. PA process consistency is ensured by consistent prior authorization and step therapy requirements, measured by MMIT.

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Completing Prior Authorization

A helpful guide on how to complete a prior authorization.

https://main--ewi-mounjaro-aem-us--elilillyco.aem.page/assets/pdf/prior-authorization-tips-guide-update.pdf

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Letter of Medical Necessity

Many health plans require a Letter of Medical Necessity to accompany a coverage authorization appeals letter.

https://main--ewi-mounjaro-aem-us--elilillyco.aem.page/assets/pdf/tzp-hcp-sample-letter-of-medical-necessity-2025.pdf

Savings are available to get your patients started on Mounjaro | savingsprogram

https://main--ewi-mounjaro-aem-us--elilillyco.aem.page/fragments/savings-resources

https://main--ewi-mounjaro-aem-us--elilillyco.aem.page/fragments/hcp/savings-resources/additional-formulary-info