Zepbound insurance coverage: What to know

Key takeaways

• Insurance coverage for Zepbound (tirzepatide), a GLP-1 medication for weight loss, varies widely by plan. Many insurers require prior authorization showing you meet criteria like BMI thresholds, have tried other treatments, or participate in lifestyle changes.
• If your coverage is denied, you can appeal the decision within 6 months. Many insurance denials are successfully appealed when people submit supporting evidence from their doctor.
• If coverage or appeals are denied, savings options include manufacturer programs from Eli Lilly, prescription discount cards, self-pay pricing, and government programs like TrumpRx or expanded Medicare coverage.

Overview

Zepbound (tirzepatide) is a dual glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) receptor agonist, commonly categorized alongside other GLP-1 medications. It’s used to reduce body weight in adults with obesity or adults with overweight in the presence of at least one weight-related comorbid condition.

Zepbound coverage depends on your plan, why it has been prescribed, and whether you meet certain requirements of your plan. If coverage is denied, you can also appeal the decision.

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Is Zepbound covered by insurance?

There is wide variation between employer and individual plans as to whether GLP-1s for weight loss, like Zepbound, are covered. GLP-1 coverage is often limited because many plans consider weight loss to be a cosmetic purpose rather than a medical one. However, coverage may be expanding.

Insurance coverage for Zepbound typically depends on your plan and what it’s being used to treat. Insurers are more likely to cover Zepbound if it’s used for an approved purpose and you meet specific prescribing criteria. Using a GLP-1 for a use not approved by the FDA is known as off-label prescribing.

Here are a few ways that can help you find out whether your insurance plan covers Zepbound. For instance, you can:

• Visit your insurance company’s website: This can help you locate the formulary of your specific plan.
• Review your plan’s summary of benefits and coverage: You can request this information from your insurer or view a copy online.
• Review any materials your plan provider emailed you: This should include information on what drugs are covered under your plan.
• Call your insurance company: You can use the general number for plan members. You can ask the agent whether your plan covers a certain medication.

How to get coverage

The requirements to qualify for a Zepbound prescription are that you are an adult and have one of the following:

• obesity alone
• moderate to severe obstructive sleep apnea and obesity
• overweight and at least one weight-related co-occurring condition, such as high blood pressure, type 2 diabetes mellitus, or high cholesterol

Sometimes, your insurer will request prior authorization from your doctor before approving Zepbound coverage. Prior authorization is a process where your insurance provider asks your doctor to prove that a treatment is medically necessary for you. For weight management, this may involve the doctor submitting documents that show:

• that you meet certain criteria, like BMI thresholds
• that you have tried less expensive treatments that haven’t worked, a process known as step therapy
• participation in a weight-management program or using a health app to track your progress
• that you have implemented lifestyle changes, like a reduced-calorie diet and increased exercise

The insurer will then review the request and approve or deny it, or ask for more information. If they deny the request, you have the right to appeal the decision or pay out of pocket for the medication.

How to appeal an insurance denial

If your insurance has rejected coverage, you can still appeal the decision. This will make your insurer take another look at your circumstances. Most initial denials are automated, and according to some 2023 data, around 44% of insurance denials are successfully appealed when a person takes a look.

You must submit an appeal within 6 months. Here’s a step-by-step guide for how to appeal a denial:

Step 1: Understand why you were denied

If your coverage is denied, your insurer should let you know why. This should help you know what evidence you need to gather to show why the medication should be covered.

For example, if your insurer thinks you don’t meet the prescribing criteria, you can get evidence from your doctor showing that you do.

Step 2: Write your appeal letter

Every appeal letter will look different. But here are some tips you can follow for writing the letter:

• Make sure you have the correct policy number and appeal department.
• Include the reason for the denial and your request.
• Detail your health history, including previous treatments that you’ve tried.
• Explain why Zepbound would be the most effective treatment for you.
• Mention the risks associated with stopping treatment.

Your doctor can help you with this process and provide any evidence or recommendations needed.

Medical perspective

How long will it take to hear back from an insurance appeal?

“Most insurance appeals can range anywhere from a few weeks to months. This depends on how urgent the case is and whether all the needed documents have been provided. If additional information or clarification is needed, this can cause the decision to take longer.”

— Alex Nguyen, PharmD, RPh, CPh

Note: Quotes represent the opinions of our medical experts. All content is strictly informational and should not be considered medical advice.

How to save money even if coverage is denied

If your appeal has also been denied, there are many other ways to save on the costs of Zepbound if you’re paying out of pocket:

• Manufacturer savings programs: Zepbound’s manufacturer, Eli Lilly, offers a few different savings options to help you save on your Zepbound prescription based on your individual situation.
• Prescription discount cards and coupons: Some third-party companies, including Optum Perks, offer a free or low cost discount card that can help you save on many medications, including GLP-1s.
• Government programs: TrumpRx is a platform that allows people to find and access discounted drug prices for some prescription drugs, including GLP-1s. Medicare is also expanding coverage for GLP-1s for obesity.

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Online care for Zepbound

If a doctor has prescribed a GLP-1, it’s important to take the medication as directed for as long as your doctor recommends. However, some people might face barriers to accessing GLP-1s, including high costs and access to healthcare appointments.

With Optum Perks Online Care, you can request a new weight loss prescription, get a refill, or get help with an existing prescription. There’s no monthly membership needed — all you’ll pay is $39 for the appointment plus the cost of the medication.

With this service, you can submit an online form answering a few questions about your condition, and a licensed healthcare professional will respond soon after, without the need to make an in-person appointment.

Next steps

If you’re thinking about starting Zepbound, here are some next steps to consider to make sure it’s covered by insurance:

• Check out your formulary. Look up any information from your insurance to see whether GLP-1s are covered for weight loss.
• If you’re not sure, call your insurer. An agent should be able to chat through your coverage with you.
• Ask your doctor for prior authorization if your insurance needs this.
• If your request is denied, write an appeal.
• If your request is denied again, consider savings options if you’re paying out of pocket.

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Download the free Optum Perks Discount Card to save up to 80% on many prescription medications. Plus, you can now get them delivered to your home in as little as 3 days. Search for your medication here.