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Is Zepbound covered by insurance?

Key highlights:

• Zepbound is an FDA-approved injectable medication for weight loss in people with obesity and overweight with one weight-related health condition medication.

• The list price for Zepbound without insurance is $1,059.87 for 1 month's supply which is $264.97 per week or $13,778.44 per year.

• Insurance coverage for Zepbound depends on your plan, deductible, and copay amounts, and may require prior authorization.

• Most government-funded plans don’t cover Zepbound and other weight loss medications. Coverage through private or commercial plans can vary.

• You can save using a Zepbound Savings Card and pharmacy discounts.

Zepbound (tirzepatide) is an FDA-approved injectable medication for weight loss in adults with obesity or overweight and one or more weight-related health conditions. It’s also approved for obstructive sleep apnea.

Insurance coverage is very useful for making Zepbound affordable and accessible. It helps reduce the cost so the medication is available to those who need it.

Are you thinking about using Zepbound for weight loss? Are you wondering what’s the cost and will insurance cover it? Read on to find out about insurance coverage for Zepbound, and how to navigate the process to make it more affordable.

What is Zepbound?

Zepbound (tirzepatide) is an FDA-approved injectable prescription medication used to help adults with obesity (a body mass index of 30 or higher) or overweight (a body mass index of 27 or higher) who also have at least one weight-related health condition, like high blood pressure, type 2 diabetes, high cholesterol, obstructive sleep apnea, or cardiovascular disease. It is meant to be used along with a healthy, lower-calorie diet and increased physical activity to help manage weight.

In a 72-week SURMOUNT-1 trial, Zepbound was shown to achieve an average weight loss of up to 20.9% in just a year and a half.

Zepbound (tirzepatide) is the first and only prescription medication for adults with moderate-to-severe obstructive sleep apnea in adults with obesity. This FDA approval is based on the results of the SURMOUNT-OSA phase 3 clinical trials.

Zepbound helps with significant weight loss, reduces appetite, and improves blood sugar levels, making it a priority for patients looking to manage weight, control hunger, and improve conditions like diabetes and high blood pressure.

The list price of Zepbound is $1,059.87 according to the manufacturer, Eli Lilly. The retail price that you will pay depends on where you are located and which pharmacy you buy from.

Does insurance cover Zepbound?

It depends on your insurance plan. Since Zepbound is a new and expensive weight loss medication, coverage isn’t always guaranteed. Insurance companies may take time to add new drugs to their plans, and even when they do, newer medications like Zepbound can have higher out-of-pocket costs.

Insurance companies often cover medications like Zepbound if they are prescribed for conditions such as obstructive sleep apnea, especially when other treatments haven't worked. However, most plans don’t provide coverage for weight loss drugs. If weight loss drugs are covered by your insurance provider, they may require proof of a doctor's recommendation and that the patient is making lifestyle changes, like diet and exercise.

Zepbound is FDA-approved for weight loss and obstructive sleep apnea. FDA approval helps make it more likely that insurance companies will cover the medication, but coverage still depends on specific insurance policies and criteria.

Some insurance companies, like Blue Cross Blue Shield and UnitedHealthcare, may cover Zepbound, but it varies by plan. Patients may need to meet certain requirements, such as proving the medication is medically necessary or showing other treatments didn’t work (step therapy).

To find out if your insurance covers Zepbound, contact your insurance company using the phone number listed on the back of your insurance card.

You can also check your insurance provider's website for their drug formulary, which lists all covered medications and their tiers. Lower-tier drugs usually have lower copays, while higher-tier drugs may cost more.

Which insurance providers cover Zepbound for weight loss?

Insurance companies have traditionally been less likely to cover weight loss medications. Some insurance companies cover Zepbound, but coverage depends on your specific plan and the choices you make during your annual benefits selection.

Government plans like Medicare don’t cover Zepbound for weight loss, but, but some Medicare Advantage and Medigap plans may. Some Medicaid plans may cover Zepbound for weight loss, but Medicaid coverage depends on the state, so check your state's drug list. Congress has proposed a new bill to expand Medicare and Medicaid coverage for weight loss drugs.

If you have VA health insurance, Zepbound may be covered under the MOVE! Weight Management Program. TRICARE may also cover it in certain cases with prior authorization.

Employer-sponsored insurance plans, like Aetna, Blue Cross Blue Shield, Cigna, and others, vary in coverage. Even if they offer prescription drug coverage, it may not include Zepbound. Employers typically create their formularies and decide on which drugs to cover, which can be different than the standard plans offered by the insurance companies.

The best way to find out if Zepbound is covered by your insurance is to directly contact your insurance provider for coverage details or talk to your employee benefits coordinator.

How much is Zepbound with insurance?

The cost of Zepbound with insurance depends on your plan, including your deductible and the copay for the drug. Some plans may only require a copay, while others may need you to meet your deductible first, meaning you'll pay full price until you reach it. For an estimate of your costs, contact your insurance provider.

If you have private or commercial insurance (through your employer or purchased yourself), you may be eligible for the Zepbound Savings Card, even if your plan doesn't cover it.

The savings card can reduce your costs to as low as $25 per month, depending on your private or commercial insurance coverage.

• For people with insurance coverage for Zepbound: The savings offer can lower the cost of a 1-month, 2-month, or 3-month supply to as low as $25. You can save up to $150 for a 1-month prescription, $300 for 2 months, and $450 for 3 months, with a maximum savings of $1,950 per calendar year.

• For people without insurance coverage for Zepbound: The savings offer can reduce the cost of a 1-month supply to as low as $650. You can save up to $469 for a 1-month refill, with a maximum savings of $3,283 per calendar year.

People with government-funded insurance, including Medicaid, Medicare, Medigap, DoD, VA, and TRICARE, are not eligible for the program.

How much is Zepbound without insurance?

Without insurance, the list price of Zepbound is $1,059.87 for a one-month supply. This price is set by the manufacturer, Eli Lilly, and does not include any extra charges or discounts that a pharmacy may offer.

You might find a lower cost at certain pharmacies. Eli Lilly, the maker of Zepbound, offers a savings card to help make it more affordable.

If you don’t have insurance, you could purchase Zepbound vials directly from the manufacturer’s telehealth service, LillyDirect. The 2.5 mg vial costs $399 for a 1-month prescription and the 5 mg vial costs $549 for a 1-month prescription.

Is there a generic version of Zepbound?

No, there is no generic version of Zepbound right now because it is a new medication with patent protection. While some people consider compounded medications as alternatives to generics, they are different from the FDA-approved version.

If you're looking for something similar to Zepbound, you can ask your doctor about Mounjaro, which contains the same active ingredient (tirzepatide). Mounjaro is FDA-approved for type 2 diabetes and can be prescribed off-label for weight loss when needed.

How to get Zepbound covered by insurance

To get Zepbound covered by insurance, you can try the following steps:

• Contacting your insurance company: Call the phone number on the back of your insurance card or visit their website to get in touch with customer service. Ask them about coverage for Zepbound and the steps you need to take.

• Gather necessary details: Before you contact your insurance, make sure you have the prescription for Zepbound, the dosage your doctor recommends, and the pharmacy you plan to use.

• Ask about coverage, copay, and prior authorization: When speaking with your insurance, ask if Zepbound is covered, what your copay will be, and if you need prior authorization before filling the prescription.

• Tools and resources to verify coverage: You can check your insurance provider’s website or use their mobile app to verify if Zepbound is covered. Some insurers also have online forms to help with medication coverage questions. You can also check coverage details on the manufacturer’s website.

Why does my insurance company require prior authorization?

Your insurance plans will likely require prior authorization for Zepbound. Some plans like Blue Cross Blue Shield of Massachusetts have a separate prior authorization form for weight loss medications including Zepbound.

Prior authorization (PA) is a process where your insurance company requires prior approval before they will cover a medication or treatment to ensure that the medication is medically necessary and meets the insurance company’s criteria. It’s also to ensure the treatment is appropriate, effective, and cost-effective.

During the PA process, your insurer will ask your doctor for information on your medical condition to see if you meet the FDA criteria for Zepbound.

To make the prior authorization process go smoothly, work with your healthcare provider to make sure all necessary information or documentation is provided, including your treatment history. Submit the required forms, follow up with your insurance company, and be patient as it may take time.

Insurance companies will often ask for proof you’ve tried diet and exercise before or will continue to do so along with the weight loss medication. They may also ask for a list of other weight loss medications you’ve tried.

Your doctor will also need to confirm you meet the eligibility criteria for Zepbound. The FDA has approved Zepbound for use with diet and exercise in adults with a body mass index (BMI) of:

• 30 or higher (obesity), or

• 27 or higher with a weight-related health condition, such as high blood pressure, high cholesterol, type 2 diabetes, sleep apnea, or heart disease.

The FDA also recently approved Zepbound for obstructive sleep apnea.

Prior authorization is often required for expensive medications or those not considered first-line. For Zepbound, first-line treatments may include diet, exercise, or cheaper weight-loss medications. On the prior authorization form your healthcare provider will confirm you’ve tried these options and need a stronger and more effective treatment for chronic weight management.

The PA process can take a few days to a couple of weeks. If denied, you can appeal by providing additional information from your doctor or having your healthcare provider resubmit to your insurance company.

Eli Lilly has a Prior Authorization Resource Guide for Zepbound on their website to help you and your healthcare provider with the process.

Who is eligible for Zepbound?

To see if you qualify for Zepbound, you will need a prescription that meets the FDA-approved labeling:

• You may be eligible if you are obese or overweight with a related health condition like high blood pressure or high cholesterol, or if you have been diagnosed with obstructive sleep apnea.

• You may qualify if you've tried to lose or maintain weight loss through diet and exercise for at least 3 months but haven’t been successful.

However, meeting these conditions doesn’t guarantee you’ll be eligible for Zepbound coverage. Your doctor will help decide if Zepbound is right for you based on your health and medical problems, current medications, and insurance coverage of Zepbound. The final decision on the best treatment for you will be made by you and your healthcare professional.

Factors that influence Zepbound coverage

Certain factors can influence your Zepbound coverage including:

Individual health plans and their prescription drug tiers

Coverage for Zepbound depends on your specific insurance plan and the tier your plan places the medication in.

The drug tier shows you how much you might pay for Zepbound. Typically, medications in lower tiers have lower copays and costs compared to those in higher tiers.

Regional differences in coverage policies

Insurance coverage for Zepbound can vary by region, as different areas may have different policies or formularies.

Your state may offer coverage for Zepbound. Check your state's preferred drug list to confirm.

Updates to insurance policies based on changing medical guidelines

Insurance companies may update their coverage policies as new medical guidelines or treatments become available, which could impact whether Zepbound is covered.

Insurance companies may take some time to cover new prescription drugs. Even when they do, newer and more expensive drugs like Zepbound might have higher out-of-pocket costs.

How to save on Zepbound without insurance

To save on Zepbound without insurance, you can try these options to reduce your out-of-pocket costs.

• Zepbound Savings Card: Use the Zepbound savings card to save if you have private or commercial insurance coverage. If eligible, it can lower the cost to as low as $25.

• Patient Assistance Programs (PAP): Patient Assistance Programs are programs offered by drug manufacturers to provide medications at a lower cost or for free to those who need financial help. Currently, Eli Lilly’s Lilly Cares Foundation does not cover Zepbound, but this could change. Call The Lilly Answers Center Monday to Friday at 1-800-Lilly-Rx (1-800-545-5979) to see if you qualify for any other financial assistance programs.

• Pharmacy discounts and coupons: Drugs.com, SingleCare, OptumPerks, and GoodRx have discount cards for pharmacies that may help lower the cost of Zepbound.

• Alternative options such as HSA or FSA funds: If you have an HSA or FSA, you can use those funds to help pay for Zepbound.

• Single-dose vials: Lower doses of Zepbound (2.5 mg and 5 mg) are available in single-dose vials through LillyDirect, which can be cheaper than the pens if you're paying out of pocket.

• Generic or lower-cost alternatives: While Zepbound has shown great results for weight loss, an alternative medication may be covered by your insurance such as:

  • Saxenda (liraglutide): A glucagon-like peptide-1 (GLP-1) receptor agonist approved for weight management and can help with both weight loss and blood glucose control.

  • Wegovy or Ozempic (semaglutide): Another GLP-1 receptor agonist approved by the FDA for weight management with benefits for both weight loss and improving blood sugar.

  • Trulicity (dulaglutide): A medication for type 2 diabetes that may be prescribed off-label for weight loss, lowering the risk of heart attack, stroke, or death in people who have type 2 diabetes and heart disease. 

  • Alli (orlistat): An over-the-counter medication that is FDA-approved for weight loss in overweight adults, used in combination with a reduced-calorie, low-fat diet to help people lose weight.

  • Contrave (naltrexone and bupropion): Contrave is a prescription weight loss medication that’s used in combination with a low-calorie diet and exercise.

Your healthcare provider may consider switching to a different weight loss medication based on the latest guidelines on the treatment selection for Weight Management Medications for Chronic Use.

Frequently asked questions

What insurance providers are most likely to cover Zepbound?

Insurance providers like Aetna, Blue Cross Blue Shield, and Cigna are more likely to cover Zepbound, but coverage depends on your specific plan. It's recommended to check with your insurance company to confirm if they cover Zepbound.

Are there alternatives to Zepbound that are more widely covered?

Yes, there are alternatives to Zepbound like Saxenda and Wegovy, which are more widely covered by insurance. These medications are also FDA-approved weight loss drugs and may be covered depending on your insurance plan.

What should I do if my insurance denies coverage?

If your insurance doesn’t cover Zepbound, you can appeal the decision by providing more information or asking your doctor to submit a prior authorization. You can also look into alternative medications or savings cards to reduce the cost.

Bottom line

Contact your insurance provider to verify if Zepbound is covered, what the copay is, and if prior authorization is required.

Look into the Zepbound Savings Card, pharmacy discounts, and patient assistance programs to lower your out-of-pocket costs.

Be persistent in your efforts to secure coverage and use all available resources to help make Zepbound more affordable.

Sources:

• https://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/572%20Drugs%20for%20Weight%20Loss%20prn.pdf

• https://www.lillycares.com/available-medications

• https://investor.lilly.com/news-releases/news-release-details/fda-approves-lillys-zepboundtm-tirzepatide-chronic-weight

• https://zepbound.lilly.com/assets/pdf/zepbound_Prior_Authorization_Resource_Guide.pdf

• https://zepbound.lilly.com/coverage-savings

• https://www.nejm.org/doi/10.1056/NEJMoa2206038

• https://www.tricare.mil/CoveredServices/Pharmacy/Drugs

• https://www.accessdata.fda.gov/drugsatfda_docs/label/2024/217806s003lbl.pdf

• https://www.va.gov/formularyadvisor/DOC_PDF/CRE_Weight_Management_Medications_Guidance_Rev_Jan_2024.pdf

Competitors:

https://www.formhealth.co/zepbound-insurance-coverage

https://ro.co/weight-loss/is-zepbound-covered-by-insurance/

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