Does SilverScript Cover Mounjaro? Medicare Advantage Coverage Guide 2026
If you’re enrolled in with SilverScript Part D (administered by CVS Health/Aetna) often ask whether SilverScript covers Mounjaro (tirzepatide). The short answer is: coverage is determined by several plan-specific factors.
SilverScript’s Formulary Position on Mounjaro
SilverScript Part D uses a prescription drug list that categorizes medications into cost-sharing tiers. Currently, Mounjaro is generally listed at Tier 4 (Non-preferred specialty) across SilverScript plan designs.
Practical implications:
- Cost-sharing: $100–$300+ based on plan variant and drug tier
- Prior authorization: Required — clinical documentation must be provided
- Quantity limits: Often enforced — typically one pen/month
- Step therapy: Could demand failed trial of metformin, insulin, or other treatments first
Note that the coverage gap, cost-sharing increases to 25% of Mounjaro’s cost before catastrophic coverage applies.
Coverage for Different Indications
For type 2 diabetes (FDA-approved):
- SilverScript is more likely to approve Mounjaro with appropriate documentation
- PA criteria: clinical records showing medical necessity
- Success is more likely when used on-label
For weight loss (for chronic weight management):
- Traditional Medicare does not cover anti-obesity medications under Part D
- However: 2025 policy changes broadened formulary inclusion rules for GLP-1s prescribed for obesity
- SilverScript might include additional drug benefits that cover weight management medications — review your plan’s specific formulary
How Much Does Mounjaro Cost With SilverScript
Understanding your out-of-pocket cost for Mounjaro on SilverScript depends on where you are in the benefit structure.
| Coverage Phase | Typical Cost |
|---|---|
| Initial Deductible ($590 in 2026) | 100% of cost: $1,000–$1,200/month |
| Initial Coverage | Tier 4/5 copay |
| Coverage Gap (Donut Hole) | Significant coinsurance |
| Catastrophic Coverage | $0 or small copay |
Starting in 2025, the annual cap limits your exposure — which significantly helps anyone taking Mounjaro.
How to Maximize Coverage
- Request a formulary exception — If Mounjaro is non-preferred, the prescriber can file for a coverage exception with medical necessity evidence
- Use Eli Lilly’s savings programs — Eli Lilly offers copay cards for eligible Medicare enrollees (government plan restrictions may apply)
- Compare plans during open enrollment — AEP (Oct 15–Dec 7) allows find a better-tier placement
- Check Low-Income Subsidy eligibility — Low-income beneficiaries can receive reduced Part D costs that dramatically lower out-of-pocket expenses