How to get tirzepatide with insurance?

Navigating the world of prescription medications can be daunting, especially when it comes to securing insurance coverage. Tirzepatide (Mounjaro, Zepbound) offers significant health benefits, but the cost can be a concern for many.

Getting tirzepatide insurance coverage can be tricky. In this article, we discuss how you can get the treatment you need without breaking the bank.

Why do you need to get tirzepatide through insurance for weight loss?

Technically, you don’t. But securing tirzepatide insurance coverage can greatly reduce your monthly expenses. The cost of tirzepatide can be quite high, and without insurance, you may find yourself paying out of pocket for the full price.

By working with your insurance provider, you can potentially offset these costs, making the medication more affordable and accessible.

Tirzepatide price without insurance

Without insurance, the cost of tirzepatide can be substantial. This medication is sold under two brand names—Mounjaro and Zepbound—as well as compounded options.

Pricing will vary based on several factors, but the current list prices for a one month supply are:

Mounjaro: $1,069.08
Zepbound: $1059.97
Compounded Tirzepatide: varies by compounding pharmacy ($399 on Heally)

Tirzepatide price with insurance

How much does tirzepatide cost with insurance? It depends.

Since Mounjaro and Zepbound are relatively new FDA-approved medications, the manufacturer, Eli Lilly, does not currently provide pricing data for specific insurance plans. To understand your potential out-of-pocket costs, it’s essential to contact your insurance company directly.

If your insurance plan does provide coverage, your copay will be dependent on the coverage tier the medication is listed under.

You might also be eligible for a savings card that can significantly reduce your copay down to as little as $25 for a 1- or 3-month supply.

Is tirzepatide covered by insurance?

Under the Affordable Care Act, insurance companies are mandated to provide obesity screening and counseling. They are not required to provide coverage for weight loss treatments.

So, tirzepatide insurance coverage can vary significantly from one plan to another.

To determine if your specific insurance plan covers tirzepatide, it’s important to contact your insurance provider directly. You will need to know the brand name of the medication you are being prescribed.

Insurance for Mounjaro

Mounjaro is currently FDA-approved specifically for diabetes management. So, weight loss treatment is considered an off-label use.

Insurance providers prefer to cover treatments that align with FDA-approved indications. If you’re seeking insurance coverage for Mounjaro for weight loss purposes, you may not have much luck.

To explore your options, check with your insurance provider to understand their policies regarding Mounjaro. They can inform you about potential coverage criteria, any documentation you may need from your healthcare provider, and whether prior authorization is required for treatment.

Insurance for Zepbound

Unlike Mounjaro, Zepbound does have FDA-approval for weight loss. But it only gained approval in November 2021, after being fast-tracked by the FDA. Unfortunately, even if your insurance plan does provide coverage for weight loss medications, it’s unlikely that Zepbound will be included on the formulary at this early stage.

As a relatively new medication, insurers may still be assessing its efficacy and cost-effectiveness, which could affect its availability.

Insurance for compounded tirzepatide

Insurance will not cover compounded tirzepatide. However, you can usually access compounded medications at a much lower cost than the brand name options.

What insurance covers tirzepatide?

Coverage for medications can vary significantly depending on the individual insurance plan. While some health insurance companies are generally more likely to provide coverage for weight loss medications—Blue Cross Blue Shield, Aetna, Cigna, and UnitedHealthcare—there’s no guarantee that your specific plan will include it.

You will need to review your policy details and contact your insurance provider to determine the coverage status for tirzepatide under your plan.

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

1. Check Your Plan’s Formulary

Begin by reviewing your insurance plan’s formulary to see if tirzepatide medications are included. Make sure you know the specific brand name of your prescription, as coverage can vary between Mounjaro and Zepbound.

2. Meet the Medication Requirements

If the medication is included in your plan’s formulary, you will still need to meet the minimum requirements. Familiarize yourself with any medication requirements set by the manufacturer or your insurance provider. This may include specific health conditions or previous treatment attempts that demonstrate the need for tirzepatide.

With weight loss medications, this means you need a BMI that indicates obesity (30 or higher), or a BMI of 27 or higher and at least one weight-related condition. These can include:

Heart disease
High blood pressure
Sleep apnea
Type 2 diabetes

3. Prove Medical Necessity

You may need to establish medical necessity for tirzepatide. This can involve:

Prior Authorization: Your healthcare provider might need to submit documentation to your insurance company justifying the need for the medication.
Step Therapy: Some plans may require you to try and fail on other, more established, weight loss treatments before approving coverage for tirzepatide.

What if you can’t get tirzepatide through insurance?

If you find yourself unable to get insurance to cover tirzepatide, here are some steps you can take:

Submit an Appeal. If you’ve submitted a prior authorization request and received a denial, don’t hesitate to appeal the decision. 83.2% of appeals resulted in either a partial or full overturn of the initial denial in 2022.
Consider Alternatives. If your insurance plan does not include tirzepatide medications on the formulary, consider alternatives that may have a higher rate of insurance approval. For example, Wegovy (semaglutide) is another weight loss medication that may be more readily covered, even if prior authorization is required.
Consider Compounded Tirzepatide. Compounded tirzepatide can be a more cost-effective option if you can’t get tirzepatide insurance coverage. Make sure you’re aware of the risks and do your due diligence when choosing a compounding pharmacy.
Look for Ways to Save. Look for discount programs or coupons through the pharmacy or manufacturer. You should also consider subscription plans, like Heally’s, to help offset the monthly cost of tirzepatide without insurance.

Save on Your Tirzepatide Prescription

Without insurance, tirzepatide medications can be incredibly expensive. But there are options available to help you manage the costs. Whether you’re appealing a denial, exploring alternative medications, or considering compounded options, it’s essential to stay proactive.

One of the most effective ways to save on your tirzepatide prescription? Heally’s subscription service.

With Heally, you can access affordable medications without leaving the comfort of your home. Don’t let financial barriers hold you back—register with Heally today!