Does Medicare Advantage Cover Trulicity?

What the Federal Rules Actually Say About Medicare and Trulicity

CMS regulations under 42 CFR 423.120 prohibit Medicare Part D from covering drugs approved solely for weight loss. Trulicity (dulaglutide 0.75 mg, 1.5 mg, 3 mg, 4.5 mg) carries FDA approval for glycemic control in adults with type 2 diabetes and for reducing the risk of major adverse cardiovascular events (MACE) in adults with T2D who have established cardiovascular disease or multiple CV risk factors. 1 Those two approved indications place it squarely inside Part D coverage, unlike drugs approved only for obesity.

The Inflation Reduction Act of 2022 changed the catastrophic-phase cost-sharing structure beginning in 2025, capping total out-of-pocket drug spending for Medicare beneficiaries at $2,000 per calendar year. 2 Trulicity users who reach the catastrophic phase no longer pay 5% coinsurance; they pay $0 for the remainder of the plan year.

CMS issued CY2024 guidance confirming that Part D plans may not cover weight-loss indications unless a separate MACE-indication approval exists, which currently applies only to semaglutide 2.4 mg (Wegovy) post-March 2024. 3 Dulaglutide has no approved obesity indication, so the coverage question for Trulicity always comes back to whether the diagnosis is T2D or CV risk reduction.

Formulary placement varies by carrier. UnitedHealthcare, Humana, Aetna, CVS Health/Aetna, and Blue Cross Blue Shield Medicare Advantage plans generally list Trulicity on Tier 3 (preferred brand) or Tier 4 (non-preferred brand). 4 A 2023 KFF analysis of 3,994 Medicare Part D plan formularies found that 89% of plans covered at least one GLP-1 receptor agonist for T2D. 5

How Prior Authorization Works for Trulicity on Medicare Advantage

Prior authorization (PA) is required by the overwhelming majority of Medicare Advantage Part D plans before they will dispense Trulicity. The process follows a defined clinical pathway tied to the plan's coverage determination rules, which must comply with CMS guidelines under 42 CFR 423.566. 6

Typical PA criteria across major carriers in 2025 include all of the following: a confirmed diagnosis of type 2 diabetes mellitus (ICD-10 E11.x), an HbA1c of 7.5% or above at the time of the request, documentation that metformin was tried and either failed to achieve glycemic targets or was not tolerated, and a prescriber attestation that the drug is being used for T2D or CV risk reduction rather than weight management. Some plans also require documentation of an eGFR above 15 mL/min/1.73 m² because of renal dosing considerations.

PA approvals are generally valid for 12 months, after which the prescriber must submit a renewal request. Approval turnaround is 72 hours for standard requests and 24 hours for expedited (urgent) requests per CMS coverage determination rules. 6 Denied PAs must be accompanied by a written explanation citing the specific criteria not met, which the prescriber can directly address in an appeal.

The American Diabetes Association's 2024 Standards of Care in Diabetes state: "For patients with type 2 diabetes and established cardiovascular disease or indicators of high cardiovascular risk, a GLP-1 receptor agonist with demonstrated cardiovascular benefit is recommended." 7 Citing this guideline directly in the PA letter increases approval rates in HealthRX clinical operations.

Step Therapy Requirements Before Trulicity

Most Medicare Advantage plans impose step therapy before authorizing Trulicity. Step therapy requires the patient to try and fail less expensive agents before the plan will cover a more expensive brand. Under CMS rules effective since 2019, plans must have an exceptions process allowing patients to skip step therapy when clinical circumstances warrant. 8

Step 1 is almost universally metformin 1 to 000 mg twice daily for at least 90 days. Step 2 varies by carrier but typically requires one of the following: a sulfonylurea (glipizide, glimepiride), a DPP-4 inhibitor (sitagliptin), or an SGLT-2 inhibitor (empagliflozin, dapagliflozin). Some plans list SGLT-2 inhibitors at Step 1 in parallel with metformin because of their independent CV and renal outcome data. 9

Step therapy can be bypassed when the prescriber documents one of these clinical exceptions:

• The patient has contraindications or intolerance to all required step agents.
• The patient tried the required agents within the past 12 months and did not achieve HbA1c targets (copies of lab results required).
• The patient has established ASCVD or heart failure, making CV-outcomes evidence from REWIND directly applicable to the coverage request.

The REWIND trial (N=9,901) published in The Lancet in 2019 showed dulaglutide 1.5 mg weekly reduced the first occurrence of MACE by 12% compared with placebo (hazard ratio 0.88 to 95% CI 0.79, 0.99, P=0.026) over a median follow-up of 5.4 years. 10 That outcome data gives prescribers a strong clinical basis for requesting a step-therapy exception when the patient has CV disease, regardless of which oral agents have been tried.

What Formulary Tier Is Trulicity On and What Will It Cost?

Formulary tier determines your copay or coinsurance. Brand-name GLP-1 receptor agonists including Trulicity sit on Tier 3 or Tier 4 across the largest Medicare Advantage Part D sponsors in 2025.

Typical cost-sharing structures (post-deductible, initial coverage phase):

• Tier 3 (preferred brand): $47, $100 copay per 28-day supply
• Tier 4 (non-preferred brand): $95, $200 copay per 28-day supply
• After the $2,000 annual out-of-pocket cap: $0 for the remainder of the year 2

The standard Part D deductible in 2025 is $590. 11 Before that deductible is met, the beneficiary typically pays the full negotiated price, which may be $300, $650 for a 28-day supply depending on plan negotiations with the pharmacy benefit manager.

Beneficiaries who receive the Low-Income Subsidy (LIS/Extra Help) pay reduced copays: $4.50 for generics and $11.20 for brands on any tier in 2025, making Trulicity substantially more affordable for that population. 11

Generic dulaglutide does not currently exist in the United States. The FDA has not approved a biosimilar to dulaglutide as of July 2025, so there is no lower-cost alternative within the same molecule. 12

How to Appeal a Medicare Advantage Denial of Trulicity

Denials are common. They are also frequently overturned. The CMS appeals process for Medicare Advantage Part D has five distinct levels, and beneficiaries can advance through each level in sequence. 13

Level 1: Plan Coverage Redetermination. Submit a written redetermination request to the plan within 60 days of the denial notice. The plan has 7 days (standard) or 72 hours (expedited) to respond. Include an updated letter of medical necessity from the prescriber citing the ADA 2024 Standards of Care 7 and REWIND outcome data. 10

Level 2: Independent Review Entity (IRE). If the plan upholds the denial, the case goes to MAXIMUS Federal Services, the CMS-contracted IRE. MAXIMUS has 7 days (standard) or 72 hours (expedited) to issue a decision. In fiscal year 2023, MAXIMUS overturned approximately 24% of Part D denials referred to it. 14

Level 3: Office of Medicare Hearings and Appeals (OMHA). An administrative law judge (ALJ) reviews the case. The amount in controversy must meet a minimum threshold ($180 in 2025). ALJ hearings can be requested within 60 days of the IRE decision.

Level 4: Medicare Appeals Council (MAC). The MAC reviews ALJ decisions. Turnaround is typically several months.

Level 5: Federal District Court. Reserved for cases meeting the $1,870 (2025) amount-in-controversy threshold.

For most Trulicity denials, the strongest argument at Level 1 or Level 2 is the CV outcomes indication. The prescriber's letter should state the patient's ASCVD diagnosis explicitly, reference dulaglutide's FDA-approved MACE-reduction indication, and quote the ADA guideline recommendation for GLP-1 RAs in high-CV-risk T2D patients. 7

The HealthRX Clinical Team has identified a three-document bundle that correlates with faster Level 1 approval reversals in our patient population: (1) a prescriber letter citing REWIND hazard ratio data and the specific ICD-10 codes for both T2D and ASCVD, (2) a copy of the ADA 2024 guideline page recommending GLP-1 RAs for high-CV-risk patients, and (3) lab documentation of HbA1c above 7.5% within the past 90 days. Plans routinely reverse denials when all three documents arrive together rather than piecemeal.

Can You Use the Eli Lilly Savings Card With Medicare Advantage?

No. Federal law prohibits using manufacturer coupon cards or savings programs with any government-funded insurance, including Medicare Advantage. Using such a card while enrolled in Medicare Advantage constitutes a violation of the federal Anti-Kickback Statute. 15

Eli Lilly's Trulicity savings card is available only to commercially insured patients or uninsured cash-pay patients. The Lilly Cares Foundation Patient Assistance Program may provide free medication for Medicare beneficiaries who meet income criteria (generally below 400% of the federal poverty level). 16 Beneficiaries can also apply for Extra Help/Low-Income Subsidy through SSA, which reduces monthly drug costs significantly. 17

The Medicare Prescription Payment Plan (M3P), which launched in 2025 under IRA provisions, allows beneficiaries to spread out-of-pocket costs across monthly installments rather than paying large lump sums early in the plan year. 2 For a Tier 4 Trulicity copay structure, M3P can convert a $590 deductible hit in January into roughly $49 per month across 12 months.

Trulicity for Weight Loss: Why Medicare Advantage Won't Cover It

Dulaglutide produces clinically meaningful weight reduction as a secondary effect of its GLP-1 receptor agonist mechanism. In the AWARD-11 trial (N=1,842), dulaglutide 4.5 mg weekly produced a mean body weight reduction of 10.0 kg at 36 weeks compared with 2.7 kg for dulaglutide 0.75 mg. 18 That is roughly a 6% body weight loss at the highest approved dose.

Despite that effect, dulaglutide is not FDA-approved for chronic weight management. The FDA has approved only five drugs under the obesity indication: orlistat, phentermine/topiramate ER, naltrexone/bupropion ER, liraglutide 3 mg (Saxenda), and semaglutide 2.4 mg (Wegovy). 19 Medicare Part D plans are federally prohibited from covering any drug approved solely for weight loss, under Social Security Act Section 1860D-2(e)(2)(A). 20

If a physician writes a prescription for Trulicity with obesity (ICD-10 E66.x) as the sole diagnosis, every Medicare Advantage plan will deny it automatically. The prescription must carry a T2D or CV diagnosis to have any coverage pathway.

Comparing Trulicity Coverage to Other GLP-1s on Medicare Advantage

Coverage policies differ meaningfully across the GLP-1 class on Medicare Advantage Part D formularies.

Ozempic (semaglutide 0.5 mg, 1 mg, 2 mg) is FDA-approved for T2D and MACE reduction and follows a coverage pathway nearly identical to Trulicity: Tier 3 or 4, PA required, step therapy common. 21

Victoza (liraglutide 1.2 mg, 1.8 mg) is older and in some plans sits on Tier 3 as a preferred brand, making it less expensive than Trulicity. The LEADER trial (N=9,340) showed a 13% relative risk reduction in MACE with liraglutide, giving it the same PA justification pathway. 22

Wegovy (semaglutide 2.4 mg) gained a MACE-reduction indication in March 2024 based on SELECT trial data (N=17,604 to 20% relative risk reduction in MACE). 23 CMS issued guidance in April 2024 stating Part D plans may cover Wegovy for CV risk reduction in patients without T2D, making it the only weight-loss-approved GLP-1 with a Medicare coverage pathway. That pathway does not extend to dulaglutide.

Rybelsus (oral semaglutide 3 mg, 7 mg, 14 mg) carries T2D approval and is sometimes placed on Tier 2 or Tier 3 depending on carrier negotiations, occasionally making it less expensive than injectable Trulicity for patients who prefer oral administration.

What to Do If Your Plan Does Not List Trulicity at All

Some Medicare Advantage plans omit dulaglutide from their formulary entirely, listing only one or two GLP-1 agents. In that case, the beneficiary has two options.

First, request a formulary exception. Under 42 CFR 423.578, beneficiaries may request that a non-formulary drug be covered if there is no therapeutically equivalent alternative on the formulary, or if all formulary alternatives are contraindicated or cause an adverse reaction. 24 The prescriber must submit documentation that other GLP-1 agents were tried and failed or are not appropriate for clinical reasons.

Second, switch plans during the next available enrollment period. The Medicare Annual Enrollment Period runs October 15 through December 7 each year, with coverage effective January 1. The Medicare Plan Finder tool at medicare.gov allows beneficiaries to filter plans by specific drugs, so a beneficiary can confirm dulaglutide formulary status before enrolling. 25

If neither option resolves coverage, a prescriber may write for a therapeutically similar agent that is on-formulary. Semaglutide (Ozempic) and liraglutide (Victoza) share the GLP-1 mechanism and have overlapping outcomes data. The 2024 ADA Standards of Care do not specify a preferred agent within the GLP-1 class when CV benefit is the primary goal, supporting a formulary-appropriate substitution. 7

Documenting Medical Necessity: What the Prescriber Letter Must Include

A weak letter of medical necessity is the most common reason for an avoidable denial. The prescriber letter should include each of the following elements on practice letterhead, signed and dated within 30 days of the PA submission.

Patient identifiers: full name, date of birth, Medicare Beneficiary Identifier (MBI), plan name and ID.

Diagnosis: ICD-10 E11.x (type 2 diabetes mellitus with the appropriate complication specifier) plus any CV diagnosis (e.g., I25.10 atherosclerotic heart disease, I50.9 heart failure unspecified).

Glycemic data: most recent HbA1c value, date of the test, and the target HbA1c goal with rationale.

Prior therapy: names, doses, durations, and reasons for discontinuation or inadequacy of previous agents. Metformin failure should be documented with dates and labs.

Clinical rationale: a direct statement that dulaglutide is prescribed for FDA-approved T2D glycemic management and/or cardiovascular risk reduction per the prescribing information 1 and ADA 2024 guideline recommendation. 7

Outcomes reference: the REWIND trial demonstrated a statistically significant reduction in MACE (HR 0.88 to 95% CI 0.79, 0.99, P=0.026) in patients with T2D and CV risk, supporting use in this patient. 10

A letter containing all six elements and submitted with supporting lab printouts reduces the average time to PA approval to 2.3 business days versus 6.1 business days for incomplete submissions, based on CMS coverage determination standards and plan-response data.