Is Zepbound Covered by Insurance?
Zepbound™ insurance coverage depends on your insurance company, as well as the medication coverage outlined in your individual plan. Each individual will have a list of medications that are covered (the prescription “formulary”) along with whether or not there are specific eligibility requirements for each medication. For example, your insurer may require that you meet the prescribing criteria set by the drug manufacturer. If you don’t meet this criteria, your insurance plan may not cover Zepbound.
The best way to get Zepbound is to work with an experienced medical provider, like those at FORM, to determine if this medication is appropriate for you as part of an overall weight loss treatment plan. If a medication is prescribed, FORM will submit necessary paperwork, such as a prior authorization, to your insurance company to request coverage.
How much does Zepbound cost without insurance?
Zepbound is expensive and therefore may be difficult to afford without insurance coverage. At the time of publication, the list price for Zepbound is about $1,060 for a 1-month supply. You may be able to find a lower cost at specific pharmacies. The manufacturer of Zepbound, Eli Lilly, offers a savings card program to make Zepbound more accessible for those who need it. Those without insurance, may be eligible to pay as low as $550 for a 1-month prescription of Zepbound, approximately 50% lower than the list price.
How much does Zepbound cost with insurance?
The cost of Zepbound with insurance will vary depending on your insurance company and your specific insurance plan, ranging from zero dollars per month if you have full coverage to higher amounts if you have partial coverage or need to meet your deductible first. Individuals with insurance can also benefit from the Zepbound savings card, which offers a 1-month or 3-month prescription for as low as $25.
Which Insurance Providers Cover Zepbound?
Many, but not all, insurance companies provide coverage for Zepbound. Your specific coverage depends on the plans available through your employer and the choices you make when selecting your annual benefits. Generally, Medicare does not cover medications approved for overweight and obesity treatment, but some Medigap and Medicare Advantage plans for retirees may cover Zepbound. Medicaid coverage varies by state, so it's advisable to directly contact your insurance provider for details. However, it's important to note that FORM currently does not accept Medicaid insurance for program costs.
Does using FORM affect the cost or coverage of Zepbound?
When you join FORM, you will have an intake appointment with your FORM doctor to review your medical history, weight loss journey, labs, and your goals. This discussion will inform your personalized weight loss treatment plan which will address nutrition, physical activity, and mindset shifts and may include a prescription for FDA-approved medication, if appropriate. Zepbound is one of many FDA-approved medications prescribed by FORM medical providers. FORM patients fill their prescriptions at their preferred pharmacy, so medication cost does not change when working with FORM. FORM does not ship medications directly to patients. Your medication coverage is not affected when working with FORM as coverage is determined by your insurance company and your specific plan.
Your FORM Care Team has experience completing prior authorizations specifically for weight loss medications, a process required by many plans to get coverage for these medication. If the initial medication that your doctor prescribes is not covered, and not affordable as an out-of-pocket option, your doctor will pursue other options, including lower cost medications that are affordable regardless of insurance coverage.
Can you get the generic version of Zepbound for less?
There is no generic version of Zepbound available at this time, as Zepbound is a new medication with patent protection. You may have heard of compounded medications, which some believe to be the equivalent of a generic but it is actually different from the medication approved by the FDA. Read more about FORM’s stance on compounded weight loss medications and why we do not recommend using them.
If you are looking for a medication that is similar to Zepbound you may consider asking your healthcare provider about Mounjaro®, which contains the same active ingredient (tirzepatide) as Zepbound. Mounjaro is FDA approved for the treatment of type 2 diabetes and can be prescribed off-label for weight loss when appropriate. Working with a program like FORM, your doctor will help determine which medication could be appropriate for you given your health history, goals, and insurance coverage.
Who is Eligible for Zepbound?
To determine if you meet the criteria for Zepbound, several factors are considered:
- Body Mass Index (BMI): If your BMI is 30+ or 27+ and you have a weight-related medical condition such as high blood pressure or high cholesterol, you may be eligible.
- Previous attempts to lose weight: If you have attempted to lose weight through lifestyle changes such as a low calorie diet and exercise for at least 3 months and been unable to lose or maintain weight loss, you may qualify.
It is important to understand that meeting these conditions does not guarantee eligibility for Zepbound. Other aspects including your medical history, current medications, and insurance coverage need to be considered. The ultimate decision about which FDA-approved medication is right for you, if any, will be reached through a discussion between you and your FORM doctor.
Disclaimer: The content made available on The FORM Medical Weight Loss Blog represents the views and opinions of the authors and not those of other entities, such as the manufacturers of products mentioned therein.
Zepbound™ and its delivery device base are registered trademarks owned or licensed by Eli Lilly and Company, its subsidiaries, or affiliates.