MOUNJARO 5 mg/.5mL Injection, Solution

Also known as Tirzepatide. Coverage in New York (CMS PDP Region 03).

10 of 10 stand-alone Part D plans in New York cover this drug on tier 3–6.

Lowest 30-day cost $11.00 at a preferred pharmacy. 10 of 10 plans apply a prior authorization, step therapy or quantity limit.

171 Medicare Advantage plans in NY do cover it

Medicare Advantage plans carry their own formularies, separate from stand-alone Part D. A patient on an MA-PD plan may have coverage even where no PDP lists the drug. NY: 171 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$35.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$520.5633	$1,041.132 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$505.2380	$1,010.482 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$520.6750	$1,041.352 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$563.8648	$1,127.732 units	Prior authorization Quantity limit 2 per 28 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$532.1016	$1,064.202 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	3Preferred Brand	17%	12%	$532.1016	$1,064.202 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$563.8648	$1,127.732 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$532.1016	$1,064.202 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$540.5889	$1,081.182 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	6Select Care Drugs	$11.00	$33.00	$505.2380	$1,010.482 units	Prior authorization Quantity limit 2 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity.

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