Zepbound Insurance coverage varies, depending on the specific insurance plan. Some plans may cover Zepbound without any restrictions, while others may require Prior authorization (prior auth, or PA) or have other limitations.
It is important to check with your insurance provider to determine your specific coverage for Zepbound.
As a general rule, Zepbound is more likely to be covered by insurance plans for adults who have:
- A body mass index (BMI) of 40 or higher
- A BMI of 35 or higher with at least one weight-related health condition, such as type 2 diabetes, high blood pressure, or sleep apnea
Zepbound for Tricare
Zepbound is currently not covered by TRICARE, the Department of Defense health insurance program. This means that TRICARE beneficiaries will need to pay the full cost of Zepbound out-of-pocket.
TRICARE does, however, cover other weight management medications, such as Wegovy and Saxenda. These medications are both glucagon-like peptide-1 (GLP-1) receptor agonists, which work by increasing levels of the hormone GLP-1 in the body. GLP-1 helps to regulate appetite and blood sugar levels.
Wegovy and Saxenda are both FDA-approved for the treatment of chronic weight management in adults with a BMI of 35 or higher, or a BMI of 30 or higher with at least one weight-related health condition.
TRICARE beneficiaries who are considering using Zepbound for weight management should talk to their doctor about other options that may be available to them.
Zepbound for Medicare and Medicaid Patients
Medicare and Medicaid do not currently cover Zepbound (tirzepatide) for the treatment of chronic weight management in adults.
Some of the possible reasons why Medicare and Medicaid may not cover Zepbound:
- The cost of Zepbound is high.
- Being a newly approved medication by FDA, there is limited data on the long-term safety and efficacy of Zepbound.
- Medicare and Medicaid are government-funded programs that have to be careful about how they spend their money. They typically only cover medications that have been proven to be safe and effective.
Despite these challenges, there is some hope that Medicare and Medicaid may cover Zepbound in the future. Eli Lilly and Company, the manufacturer of Zepbound, is working with Medicare and Medicaid to get the medication covered. They are also conducting clinical trials to gather more data on the long-term safety and efficacy of Zepbound.
If your insurance plan does not cover Zepbound, you may still be able to get the medication at a discounted price through a patient assistance program. Eli Lilly and Company, the manufacturer of Zepbound, offers a patient assistance program called Lilly Cares that can help eligible patients get the medication for free or at a reduced cost.