Key takeaways
- Insurance may cover Zepbound (tirzepatide) depending on your plan and the specific condition being treated. To determine whether your plan covers Zepbound, contact your insurance provider directly.
- If your insurance company denies coverage for Zepbound, you can appeal the decision.
- If you do not have insurance coverage for Zepbound, you can explore other options, such as the manufacturer’s self-pay program or Optum Perks for potential cost savings.
Zepbound is a brand-name drug prescribed for weight loss, obstructive sleep apnea (OSA), and other uses in certain adults. Keep reading to learn more about getting Zepbound covered by insurance and what to do if you do not have insurance.
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How to find out if your insurance company covers Zepbound
Private health insurance plans, such as United Healthcare (UHC), Blue Cross Blue Shield (BCBS), and others, may cover the cost of Zepbound. The best way to find out whether your insurance company covers Zepbound is by calling your provider directly. A representative can check your coverage in detail and determine whether Zepbound is under the plan’s drug formulary (list of covered drugs). They can also tell you whether you will need to meet a deductible or have coinsurance or copay requirements.
Your insurance company may still require prior authorization before covering Zepbound. This means the company and your doctor will discuss Zepbound in regard to your treatment. Your insurance company may ask for certain details from your doctor, such as:
- your particular diagnosis
- your body mass index (BMI) and weight
- whether you have previously taken other similar medications for your condition
They will then determine whether the medication is covered. Keep in mind that if Zepbound requires prior authorization but you start treatment without it, you could pay the full cost of the drug. Be sure to ask your insurance company whether Zepbound requires prior authorization.
Medical Perspective
“Most prior authorizations are completed in about 7 days for standard requests or 72 hours if urgent. Typically, you will be notified through your pharmacy, prescriber, or by a mailed letter or secure message from your insurer once the decision is made.”
Olivia Taylor, PharmD, BCPS
Learn more about the cost of Zepbound with and without insurance.
Quotes represent the opinions of our medical experts. All content is strictly informational and should not be considered medical advice.
Does Medicare cover Zepbound?
Currently, Medicare does not provide coverage for Zepbound for weight loss or weight management uses. This is due to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, which excluded weight management drugs from Medicare Part D plans. (Medicare Part D covers prescription drugs.)
However, if you are prescribed Zepbound for other health conditions, such as OSA, Medicare may cover it.
If you have questions about Medicare coverage for Zepbound, talk with your Medicare plan provider or your doctor.
»Learn more about Medicare and Zepbound.
How to get Zepbound covered by insurance
In some cases, your insurance company may not cover Zepbound. If this happens, you can appeal this decision. Your insurance company should give you reasons why they don’t cover Zepbound. Once you understand the reasons, you can respond with an appeal letter.
The Obesity Action Coalition (OAC) is an obesity advocacy organization that provides sample letters to help you request Zepbound coverage from your insurance company or employer. The OAC also has other resources to help you review your insurance coverage for weight loss and weight management medications.
Your doctor can also advocate for you by providing a medical necessity justification letter for Zepbound.
How to get Zepbound covered by insurance online
To find out how to get Zepbound covered by insurance online, you will likely have to go through a telehealth platform to find a healthcare professional and provide them with your insurance information. They will submit a prior authorization to your insurance company, and you will have to wait to see if your insurance approves the drug.
If your insurance doesn’t cover it, you may be able to appeal the decision.
How to get Zepbound without insurance coverage
If you still cannot get Zepbound covered by your insurance or if you don’t have insurance, there are other options available to you. For example, you can explore the drug manufacturer’s self-pay options to check how much Zepbound would cost you out of pocket per month.
You can also visit Optum Perks for price estimates of Zepbound when you use the Optum Perks coupon.
If you have questions about how and where to get Zepbound without insurance coverage, you can talk with your doctor or pharmacist.
»MORE:Search your medication on Optum Perks to see available coupons and download a free Optum Perks discount card.
Optum Perks is owned by RVO Health. By clicking on this link, we may receive a commission. Learn more.
Summary
Some insurance plans may cover Zepbound depending on your type of coverage, eligibility, and diagnosis. You can talk with your insurance provider, doctor, or pharmacist to learn whether you can get Zepbound covered by your insurance company.
Understanding your insurance options can help you get medically necessary medications like Zepbound and determine how much you will pay for the drug.
Disclaimer: While Medical News Today strives for factual, comprehensive, and current information, this article is not a substitute for a licensed healthcare professional’s expertise. Always consult a doctor before taking or discontinuing any medication. Drug information is subject to change and may not cover all uses, directions, precautions, warnings, interactions, reactions, or adverse effects. The lack of a warning does not guarantee a drug’s safety, effectiveness, or appropriateness for all patients or specific uses. Learn more about our approach to content integrity.