Does Medicare cover Mounjaro in North Carolina?

What Mounjaro is used for

Mounjaro is a once-weekly injection that acts on two hormone receptors (GIP and GLP-1). Its FDA label covers improving blood sugar control in adults with type 2 diabetes, along with diet and exercise.

This page explains Medicare coverage only. Questions about whether Mounjaro is right for you belong with your prescriber.

Which part of Medicare covers Mounjaro

Mounjaro is a pen you use at home, so it's a Part D drug. Because federal law keeps weight-loss drugs out of Part D, plans may attach prior authorization to GLP-1-type drugs to confirm a diabetes diagnosis. Your prescriber can usually handle that with the plan directly.

Is Mounjaro on Medicare's negotiated-price list?

No. Mounjaro is not among the drugs CMS has selected for the Medicare Drug Price Negotiation Program so far: the 10 drugs with negotiated prices for 2026, the 15 for 2027 and the 15 selected in January 2026 for 2028.

Mounjaro vs. Zepbound under Medicare

Both contain tirzepatide, but Medicare treats them as different products:

• Mounjaro: covered by Part D plans that list it, for type 2 diabetes.
• Zepbound for sleep apnea: Zepbound is FDA-approved for moderate to severe obstructive sleep apnea in adults with obesity, a use that isn't weight loss alone, so a Part D plan can cover it for that if it's on the formulary.
• Zepbound for weight management: not covered by Part D plans, but the Zepbound KwikPen is one of the drugs in the Medicare GLP-1 Bridge (July 1, 2026, to December 31, 2027) for eligible people. People with type 2 diabetes or moderate to severe sleep apnea aren't eligible for the Bridge.

More in Zepbound.

What you pay for Mounjaro in 2027: the out-of-pocket cap

Your cost for Mounjaro depends on your plan: its deductible, the tier it puts the drug on, and whether you use a preferred pharmacy. This site doesn't list plan costs; your plan's formulary and Evidence of Coverage do. What Medicare sets for everyone with Part D is the limit:

• 2027 out-of-pocket cap: $2,400 (it was $2,100 in 2026). Once what you pay for covered Part D drugs (deductible, copays and coinsurance) reaches the cap, you pay nothing more for covered Part D drugs for the rest of 2027.
• The maximum Part D deductible for 2027 is $700. No plan can set a higher deductible, and some have none.
• Only covered drugs count. If your plan doesn't cover Mounjaro and you pay cash, or you use a discount card instead of your plan, that spending doesn't count toward the cap.

Spreading the cost: the Medicare Prescription Payment Plan

Every Part D plan and Medicare Advantage plan with drug coverage offers the Medicare Prescription Payment Plan. Instead of paying the pharmacy, you get a monthly bill from your plan that spreads your costs across the calendar year. Medicare.gov says there's no cost to participate and no interest, but it doesn't lower your drug costs; it only changes when you pay. It helps most when costs are high early in the year. To join, call your plan or use its website. More in What is the Medicare Prescription Payment Plan?

Extra Help with Mounjaro

Extra Help (the Low-Income Subsidy) is a federal program that lowers Part D premiums, deductibles and copays. For 2027, CMS caps Extra Help copays for covered drugs at $5.80 for a generic and $14.40 for a brand-name drug, and some people with full Medicaid pay less. You get Extra Help automatically if you have full NC Medicaid, SSI or a Medicare Savings Program, which North Carolina calls MQB (MQB-Q, MQB-B or MQB-E). Otherwise, apply through Social Security at ssa.gov/extrahelp or 1-800-772-1213 (TTY 1-800-325-0778). See Extra Help in North Carolina and MQB in North Carolina.

Getting Mounjaro covered in North Carolina

North Carolina is its own Part D region (PDP Region 08), so each standalone Part D plan sold here is offered in all 100 counties. For 2027, CMS lists 11 standalone Part D plans from 6 companies in North Carolina. Every county also has Medicare Advantage plans open to everyone, from 11 in Carteret County to 57 in Guilford County. Each plan has its own formulary, so one plan's coverage of Mounjaro tells you nothing about another's. Your county's numbers are on North Carolina counties.

State Health Plan retirees: the Plan's Base Plan and Enhanced Plan are group Medicare Advantage plans that include group Part D, so your Mounjaro coverage comes from the Plan's formulary. Don't join a separate Part D or Medicare Advantage plan to get Mounjaro covered: the State Health Plan says that removes you from its group Medicare Advantage plan and moves you to the 70/30 Plan. Ask the Plan first. See the State Health Plan and Medicare.

If you have full NC Medicaid and Medicare, your Medicare drug coverage, not NC Medicaid, pays for Part D drugs like Mounjaro, and you get Extra Help automatically. See NC Medicaid and Medicare.

If your Medicare Advantage plan ends in 2027, your plan sends a non-renewal letter, and you have a special enrollment period through February 28, 2027. To keep Mounjaro covered without a gap, choose new drug coverage by December 31, 2026. See plans ending in 2027.

Hurricanes and power outages: Mounjaro has storage-temperature limits on its label, so a long power outage can ruin your supply; keep your plan's pharmacy number with your emergency supplies. CMS says Medicare pays to replace prescription drugs lost, destroyed or damaged in a disaster; call your plan for a replacement fill. North Carolina's emergency-refill law (G.S. 58-3-228) is written for state-regulated health plans and the State Health Plan; in a Medicare drug plan, ask the plan itself. See early refills before a hurricane.

How to check whether a plan covers Mounjaro

1. Write down the exact drug. Name, strength and how often you take it. A plan can cover one form or strength of Mounjaro and not another.
2. Look it up in each plan's formulary. Enter your drugs and ZIP code on PlanMatch or Medicare.gov's Plan Finder to see which plans list Mounjaro and any rules.
3. Read the rules next to the drug. Prior authorization, step therapy or quantity limits mean your prescriber may need to send the plan information before it pays.
4. Check your 2027 notice. Your plan's Annual Notice of Change says whether Mounjaro stays on the formulary next year. Open Enrollment runs October 15 to December 7, 2026, for coverage starting January 1, 2027.
5. Get help if you want it. You can request a call from a licensed insurance agent, who can compare plans from the companies they work with, or call 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048) for information on all of your options.

If your plan doesn't cover Mounjaro, you or your prescriber can ask for a coverage determination or a formulary exception. Once the plan has your prescriber's supporting statement, it generally must decide within 72 hours, or 24 hours if your prescriber says waiting could seriously harm your health. New members can usually get a one-time transition supply of a drug they were already taking while they ask for an exception or switch. See How do I appeal a Medicare denial in North Carolina?

Sources

• National Library of Medicine — DailyMed: Mounjaro prescribing information (FDA label)
• Medicare.gov — Drug coverage (Part D)
• Medicare.gov — Weight loss drugs (Medicare GLP-1 Bridge)
• CMS — Medicare GLP-1 Bridge (July 1, 2026, to December 31, 2027)
• CMS — Selected drugs and negotiated prices (Medicare Drug Price Negotiation Program)
• CMS — Selected drugs for initial price applicability year 2028 (fact sheet, January 2026)
• CMS — CY 2027 Rate Announcement (2027 Part D out-of-pocket threshold and Extra Help copays)
• Medicare.gov — Medicare Prescription Payment Plan
• Social Security — Extra Help with Medicare prescription drug plan costs
• CMS — Medicare Advantage and Part D Landscape files, 2027 (PDP Region 08: North Carolina)
• State Health Plan — Retiree presentation (group Medicare Advantage plans, outside Medicare plans and the 70/30 Plan)
• CMS — Replacing Durable Medical Equipment and Prescription Drugs after a Disaster
• North Carolina General Statutes — G.S. 58-3-228, extra prescriptions during a state of emergency or disaster

Frequently asked questions

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