How To Get Zepbound Covered By Insurance

Obesity is now widely recognized as a chronic condition. Fortunately—thanks to advancements in the medical field—there are now viable treatment options that go beyond the traditional diet and exercise.

Medications like Zepbound are game changers for individuals who have long struggled to manage their weight. However, the cost of these treatments can be significant, eliminating them as an option for many.

Getting Zepbound insurance coverage can make a significant financial difference. Let’s navigate the process of getting coverage or Zepbound insurance approval and reducing the financial burden of this treatment.

Why do you need insurance for your Zepbound prescription?

Weight loss medications are not cheap. Out-of-pocket costs without insurance coverage can be over a thousand dollars per month. Zepbound insurance coverage can make a significant difference, making the medication both affordable and accessible.

Zepbound cost without insurance

The current list price for one month (defined as 28 days and 4 pens) of Zepbound is $1059.97. Without insurance or discounts, that is the lowest you will pay out-of-pocket for this medication.

That’s $12,719.64 per year!

With Zepbound (and other weight loss medications) being designed for long term use, that cost adds up quickly. Eli Lilly, the manufacturer, does provide savings options for Zepbound. You may be able to qualify to pay as low as $650 for a one month supply. But, that can still total $7800 a year at a minimum.

Zepbound cost with insurance

If you have Zepbound insurance coverage or the ability to get Zepbound insurance approval, you will pay significantly less per month. The actual out-of-pocket cost of Zepbound with insurance will vary. It depends on:

Your insurance provider. Different providers have varying policies on covering weight loss medications like Zepbound.
Your insurance plan. The specifics of your plan, such as copays, deductibles, and formulary placement, will impact how much you pay.
Your diagnosis. Insurers may require a documented diagnosis, such as obesity or an obesity-related condition, which may impact the cost and coverage.

Due to the newness of Zepbound, Eli Lilly does not currently offer pricing for specific plans. But, you may be eligible for a savings card that can significantly lower your copay, paying as low as $25 for a 1- or 3-month supply of Zepbound.

Is Zepbound covered by insurance?

The answer to this question is not quite cut and dry. While Zepbound is a promising weight loss treatment—with FDA-approval for weight management—the most likely answer for many is, unfortunately, no. Insurance coverage for weight loss medications is inconsistent, and many providers don’t include them as part of their standard coverage.

Why is Zepbound not covered by insurance?

Even though obesity is recognized as a chronic condition, insurers are not required to cover weight loss medications like Zepbound. Under the Affordable Care Act, insurance companies are only required to provide obesity screening and counseling.

Zepbound is also a new treatment option. Many insurance companies will hold off on covering new medications until more data is available.

However, it’s still worth checking your specific insurance plan, as some do offer coverage under certain conditions, especially if you meet specific criteria or have a diagnosis tied to obesity-related health issues.

How to get Zepbound covered by insurance: step-by step guide

Checking whether or not you have Zepbound insurance coverage should be pretty straightforward. Getting Zepbound insurance approval, on the other hand, can be a bit more complicated.

1. Review Your Current Insurance Plan

The first step in getting Zepbound covered by insurance is to review your current insurance plan and its specific coverage details. You can easily access this information through your insurance app or the provider’s website.

Begin by locating the formulary, which is a comprehensive list of all covered drugs and medications under your plan. Here are key points to focus on:

Check for Zepbound: Look for Zepbound in the formulary to determine if it’s listed as a covered medication. If it’s not listed, you may need to consider alternative options or treatments.
Understand Coverage Tiers: Medications may be categorized into different tiers, which can affect your out-of-pocket costs. Generally, lower-tier medications will have lower copays compared to higher-tier ones. Make note of where Zepbound falls within these tiers.
Look for Special Requirements: Some insurance plans may have specific conditions for coverage, such as prior authorization or step therapy, and specific requirements for eligibility. Be sure to identify any such requirements that could impact your ability to access Zepbound.

2A. Submit a Prior Authorization Claim

Many insurance companies don’t offer carte blanche coverage and instead require require Zepbound insurance approval through prior authorization for weight loss medications. This means you need to prove medical necessity before you can get Zepbound covered by insurance.

Your healthcare provider must submit a request on your behalf to the insurance company to demonstrate that the medication is medically necessary for your condition. This will require thorough documentation, including your:

Medical history
Diagnosis
Comorbidities (such as type 2 diabetes, heart disease, etc.)
Previous weight loss treatments

2B. Apply for Step Therapy

Instead of prior authorization, some insurance companies will require you to begin with step therapy. This requires you to try less expensive or alternative medications before Zepbound will be approved.

If you see this requirement listed on the formulary, you will want to first reach out to your insurance provider to understand the required steps. Your provider should provide the first-line treatment as well as additional steps that will need to be taken to gain Zepbound insurance approval.

If this applies to you, consult with your doctor about trying the first-line treatment specified by your insurance plan and documenting your progress.

3. Prepare for Appeals

If your initial request for coverage is denied, don’t lose hope. You have the right to appeal the decision. You’ll need to gather additional documentation and work with your healthcare provider to provide evidence of medical necessity. This could include details about your weight loss history and any adverse effects from previous treatments.

Submit the appeal promptly and follow up with your insurance company to ensure it’s being reviewed.

What to do if insurance won’t cover Zepbound?

If insurance won’t cover Zepbound, you have two options: change providers or choose a Zepbound alternative covered by insurance.

1. Change Providers

If you discover that your current insurance plan does not cover Zepbound and offers no approval options, you may want to consider changing your insurance provider. This is not an option for many, but if it is an option for you, make sure that you’re doing your due diligence.

Keep in mind that with additional premiums, the out-of-pocket costs may end up being the same—or even more—than simply paying the Zepbound cost without insurance.

Here’s how to navigate this process:

Research Insurance Providers. It can be difficult to determine what insurance covers Zepbound. Unfortunately, there’s no comprehensive list of providers that cover these medications. Look for providers that specifically mention coverage for GLP-1 receptor agonists or weight loss medications in their policies. Make sure that these providers also cover your other medical needs.
Review Plan Details. Once you identify potential insurance providers, examine the details of their plans. Pay close attention to the formulary, copay structures, and any prerequisites for obtaining coverage, such as prior authorization or step therapy.
Confirm Coverage. Contact the insurance companies directly to confirm that Zepbound is included in their formulary. Ask about any specific requirements that may need to be met before coverage is granted. Do not skip this step. Changing insurance providers/plans is a big decision and you want actual verification of coverage before you make the switch.
Make the Switch. If you find a provider that offers robust coverage for Zepbound, initiate the process of switching your insurance. This may involve filling out applications, providing necessary documentation, and adhering to any enrollment deadlines.

Get your Zepbound prescription online

Getting Zepbound insurance coverage or approval can be challenging, but there are options that can help ease the financial burden. The pharmacy you choose plays a significant role in determining your out-of-pocket costs, so it’s essential to consider your options carefully.

You can also choose a provider with a subscription service, such as Heally, to help offset costs.

If you’re ready to take the next step in your weight loss journey, register with Heally to get your Zepbound prescription online and save. Don’t wait—take charge of your health today!