State Medicaid Mounjaro worksheet: preferred list, history checks and appeal dates

Your state program

Records a claims-history review looks for

Texas looks for these as coded diagnoses, procedures and drug fills within set look-back periods; other states may ask for chart notes instead.

• Type 2 diabetes diagnosis coded within the past year
• Metformin or another oral diabetes drug filled for at least two straight weeks
• A recent HbA1c lab test on file
• No other GLP-1 drug prescribed at the same time
• Kidney failure, pancreatitis, gastroparesis and thyroid cancer history reviewed with the prescriber

Two 2026 state documents

• Texas, April 3, 2026: a Mounjaro request needs 14 consecutive days of an oral diabetes drug or of Mounjaro in the last 365 days, an HbA1c test in the last 180 days, and no other GLP-1 drug; approval lasts 365 days.[1]
• New York, NYRx list revised September 14, 2026: Mounjaro is non-preferred for type 2 diabetes, with exenatide, Ozempic pen, Trulicity and Victoza preferred.[2]
• In New York, non-preferred drugs in these classes need prior authorization unless the list says otherwise.[2]

Federal rules every state program follows

• A Medicaid prior authorization program must respond within 24 hours of a request.[3]
• In an emergency it must allow at least a 72-hour supply of a covered outpatient drug.[3]
• Managed care members have 60 calendar days from the denial notice to appeal to the plan.[4]
• A standard managed care appeal must be resolved within 30 calendar days of receipt.[5]
• After the plan's appeal decision, the State fair hearing request window is at least 90 and at most 120 calendar days.[5]

Request, appeal and hearing log

Questions for the state pharmacy line or your plan

1. Is Mounjaro preferred or non-preferred on the list in force today, and when is the next review?
2. Was my request checked automatically against claims, or reviewed by a pharmacist?
3. Which preferred drug would be approved without extra steps?
4. Does my managed care plan follow the state list or its own formulary?
5. Where do I send an appeal, and can I ask for an expedited decision?