HealthRX.com · Printable coverage checklist
TRICARE Mounjaro authorization, cost and appeal checklist
Check the diagnosis and metformin history before the request, note which pharmacy and formulary status set your copay, and keep an appeal record with the Express Scripts deadline. Facts come from TRICARE's cost page and FAQ, the DoD Pharmacy and Therapeutics Committee's November 2025 criteria, and TRICARE's appeals page.
Before the prescription is sent
- Type 2 diabetes diagnosis in the record
- Metformin dates, dose and result, or the documented reason it cannot be used
- Ask Express Scripts whether this Mounjaro fill needs a prior authorization form
- Formulary status of Mounjaro checked in the TRICARE Formulary Search Tool
- Pharmacy chosen: military pharmacy, home delivery or retail network
- If you are active duty, confirm you pay nothing for covered drugs
For the prior authorization
Date of type 2 diabetes diagnosis
Metformin: dates, highest dose, why stopped or not used
Other diabetes medicines tried
Prescriber's name and whether they are an MTF or network provider
TRICARE rules to check against
- 2026 and 2027 copays: $44 for a brand-name formulary drug by home delivery (up to 90 days) and $48 at a retail network pharmacy (up to 30 days); non-formulary drugs are $85 at either.[1]
- Active duty service members pay nothing for covered drugs at military pharmacies, home delivery or retail network pharmacies.[1]
- New Mounjaro users need manual prior authorization under the November 2025 criteria; the automated 720-day lookback for any diabetes drug stays with Trulicity.[2]
- New users of a GLP-1 receptor agonist must try metformin first, and an approved prior authorization does not expire.[2]
- A pharmacy appeal to Express Scripts must be postmarked within 90 days of the decision; a second-level appeal is available if Express Scripts denies it.[3]
Authorization and appeal record
| Date | Form, call or letter | Express Scripts reference | Outcome | Postmark deadline |
|---|---|---|---|---|
Ask Express Scripts or your pharmacy
- Is Mounjaro formulary or non-formulary on my fill date, and what will this fill cost?
- Is a prior authorization for Mounjaro on file, and on what date was it approved?
- Which criterion was not met, if the request was denied?
- Does the military pharmacy near me stock Mounjaro?
- What supply length can home delivery send?
Sources for the facts on this sheet
- TRICARE, Defense Health Agency. Pharmacy Costs | TRICARE. Accessed 2026-10-18. https://tricare.mil/pharmacycosts
- Defense Health Agency, Military Health System (health.mil). Department of Defense Pharmacy and Therapeutics Committee Recommendations from the November 2025 Meeting: Information for the Uniform Formulary Beneficiary Advisory Panel. Accessed 2026-10-18. https://health.mil/-/media/4B0140A2A26F4718BA87BD1CF0EC2A1E.pdf
- TRICARE, Defense Health Agency. Appeals | TRICARE. Accessed 2026-10-18. https://www.tricare.mil/appeals
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.