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HealthRX.com · Printable coverage checklist

Blue Cross Blue Shield tirzepatide coverage record

Start by identifying which Blue company and which formulary governs your plan, then assemble the type 2 diabetes prior authorization file for Mounjaro and log every request. If you are a federal employee on FEP Blue, the 2026 formulary facts and the disputed claims deadlines are included.

Companion to “Does Blue Cross Blue Shield Cover Tirzepatide (Mounjaro)?” · healthrx.com/glp-1-questions/does-blue-cross-blue-shield-cover-tirzepatide-mounjaro · Facts checked 2026-10-18

Which Blue plan you have

Blue Cross Blue Shield company and state
FEP Blue option, if a federal employeeStandard, Basic or Focus
Employer plan typefully insured or self-funded
Formulary name and where you checked Mounjaro's tier

Prior authorization file for Mounjaro (type 2 diabetes)

  • Diagnosis code for type 2 diabetes on the request
  • Recent A1C, fasting glucose and kidney function results
  • Metformin: dates, maximum tolerated dose and outcome, or the documented reason it cannot be used
  • Any second diabetes medicine tried, with dates and results
  • Cardiovascular or kidney conditions documented, if the letter relies on them
  • Prescriber's letter of medical necessity

If you have FEP Blue (2026)

  • Mounjaro is tier 2 with prior approval on FEP Blue Standard, Basic and Focus.[1]
  • Wegovy is tier 3 on Standard and Basic and not covered on Focus.[1]
  • Zepbound is on the 2026 not-covered lists for FEP Blue Standard and Basic.[1]
  • Mail service and specialty pharmacies hold a prescription that needs prior approval for up to 30 days; without approval by then, it cannot be filled.[2]
  • To dispute a denial, write to FEP Blue within 6 months, then to OPM within 90 days of the letter upholding it.[2]

Requests and appeals

DateRequest, denial or appealReference numberDeadlineOutcome

Ask your Blue plan

  1. Which formulary applies to my plan, and what tier is Mounjaro on?
  2. What does the prior authorization require, and is there step therapy?
  3. Does my plan exclude weight-loss drugs, or cover them for an employer that opted in?
  4. How long is an approval valid, and does it cover every dose step?
  5. What is the deadline for an internal appeal, and how do I request external review?
Sources for the facts on this sheet
  1. Blue Cross and Blue Shield Association, Federal Employee Program. Blue Cross and Blue Shield Service Benefit Plan (FEP) 2026 Abbreviated Formulary. Accessed 2026-10-18. https://www.fepblue.org/-/media/FEPBlue-Sitecore-10-Media/PDFs/Brochures/2026/FEP2026AbbrevFormularyBook-R60-WCAG.pdf
  2. Blue Cross and Blue Shield Association, Federal Employee Program. Blue Cross and Blue Shield Service Benefit Plan 2026: FEP Blue Standard and FEP Blue Basic (FEHB plan brochure). Accessed 2026-10-18. https://www.fepblue.org/-/media/PDFs/Brochures/Standard-and-Basic-brochure-2026.pdf

This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.