If you’re seeking honest insights and support in pursuit of Zepbound (GLP-1), you’ve come to the right place. In this guide, we’ll walk you through each step to determining whether Zepbound is covered by your insurance and how to get your Zepbound prescription covered by insurance. If your insurance has denied coverage for Zepbound, check out our 5 steps to appeal a Zepbound coverage denial.

Wherever you are in your GLP-1 weight loss journey - whether you’re new to GLP-1s, previously took or attempted to get a GLP-1, or are currently taking a GLP-1 and interested in switching to Zepbound - we have you covered. Feel free to skip to the sections of this guide that are most relevant to you.

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Step by Step Guide: How to Get Zepbound Covered by Insurance
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Step 1: Understand your GLP-1 options

‍Step 2: Confirm you meet standard FDA requirements for Zepbound

‍Step 3: Review your insurance drug formulary policy for Zepbound

‍Step 4: Estimate your likelihood of receiving Zepbound coverage approval

‍Step 5: Decide on how you’ll get a Zepbound prescription

‍Step 6: Submit your personal evidence to your doctor and insurance

‍Step 7: If you are denied insurance coverage, submit an insurance appeal for Zepbound

‍Step 8: If you aren’t able to get Zepbound coverage, explore these alternative options  

Step 1: Understand your GLP-1 options (Zepbound vs Wegovy vs Saxenda)

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Key Takeaways
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• While Zepbound has been demonstrated to be the most effective GLP-1 for weight loss, Wegovy and Saxenda are also effective options.

Zepbound is the most recent GLP-1 medication indicated for use in chronic weight management, and was approved by the FDA on Nov 8th, 2023. Zepbound is produced by Eli Lilly and contains the same active medication as Mounjaro - tirzepatide. In fact, the key difference between Zepbound and Mounjaro is that Zepbound is officially approved for weight management, while Mounjaro is approved by the FDA for Type 2 diabetes management.

While clinical trials have demonstrated Zepbound to be the most effective GLP-1 for weight-loss yet, it’s not your only option. Wegovy (semaglutide) and Saxenda (liraglutide) are two other GLP-1s approved by the FDA for weight loss. When deciding which GLP-1 is right for you, you want to consider your weight loss goals, insurance coverage, side effects and budget.

While Mounjaro and Ozempic are currently only approved by the FDA for treatment of Type 2 diabetes it doesn’t necessarily mean you won’t be able to access these medications. Off-label prescription of these medications for reducing the risks of developing type 2 diabetes or for treatment of metabolic syndrome have been successful for some but this depends highly on your insurance plan and clinical profile.

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Step 2: Confirm you meet standard FDA requirements for Zepbound

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Key Takeaways

• FDA requirements are check by all insurance companies

• Zepbound is approved for adults with obesity (BMI ≥ 30) or a BMI over 27 who also have at least one weight-related medical condition.

• Honest Care’s rapid GLP-1 assessment can help you understand and document evidence of your eligibility your doctor and insurance

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Zepbound, like Wegovy and Saxenda, is approved by the FDA for adults with obesity (BMI ≥ 30) or a BMI over 27 who also have at least one weight-related medical condition including:

• Asthma
• Coronary artery disease
• Dyslipidemia
• GERD
• High cholesterol
• Hypertension
• Metabolic syndrome
• Non-alcoholic fatty liver disease
• Obstructive sleep apnea
• Osteoarthritis
• Prediabetes
• Type 2 diabetes
• PCOS

Sharing detailed evidence demonstrating your basic eligibility will increase your chance of insurance coverage approval. This means sharing your diagnosis across all weight-related conditions (not just the ones list by the FDA), including the correct ICD-10 diagnosis code within your prescription, and sharing your most recent results from lab tests such as a Comprehensive Metabolic Panel (CMP), TSH, and HbA1c tests. Honest Care offers assistance in understanding and documenting your eligibility for Zepbound and other GLP-1s.

It’s also important to note that a personal or family history of certain medical conditions may exclude you from Zepbound coverage, or may be considered a precaution while on Zepbound**. These conditions include:

• Family or personal history of medullary thyroid carcinoma (MTC)
• Multiple endocrine neoplasia syndrome type 2 (MEN-2)
• History of diabetic retinopathy
• History of gastrointestinal disease
• History of thyroid tumors or cancer
• History of kidney problems
• Currently pregnant, breastfeeding, or expecting
• Currently taking other diabetes medications

**We strongly encourage you to speak to your doctor if you have any questions regarding your medical eligibility for Zepbound, or if you have a history of any of these conditions.

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Step 3: Review your insurance drug formulary policy for Zepbound

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Key Takeaways

• Medicare doesn’t cover currently cover Zepbound but will cover Wegovy to reduce the risk of heart attack and stroke.
• Commercial and private plans generally include at least partial coverage for at GLP-1s (Zepbound, Wegovy, Saxenda), but it’s critical to understand your plan’s unique policy

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Insurance coverage is often the biggest hurdle to accessing a GLP-1, including Zepbound. To get coverage, it’s important to understand your insurance’s policies. Below are instructions on how.

Plans through private-company employers

‍Many commercial and private insurers cover weight loss medications like Zepbound, in part or in full. To find out if you plan covers Zepbound, you can try one of the following:

• Call your insurance: You should find a phone number on your insurance card. When you call, share your Member ID and ask whether Zepbound is covered on your plan’s drug formulary. When you take this step, ask about the coverage policy on Wegovy and Saxenda as well.
• You can also ask about medications such as Mounjaro and Ozempic, but keep in mind that these medications are FDA approved for the treatment of Type 2 diabetes (as we referenced in step 1).
• Check your insurance’s online portal: Most insurance plans allow you to login using your Member ID. Once you login, you should be able to find a link to your plan’s drug formulary. When you find it, search for Zepbound, Wegovy and Saxenda to understand whether they’re covered.
• Ask your employer’s HR department: Contact your employer’s HR department and ask them to provide details on your plan’s drug formulary policy for Zepbound, Wegovy and Saxenda.

If you are told that insurance coverage includes a “plan exclusion” for weight loss medications, this means your employer chose not to cover weight loss medications as a category

ⓘ Make sure to use the Zepbound Savings Card if you have commercial insurance Learn more about saving on Zepbound

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Self-purchased insurance (Affordable Care Act)

If you purchased insurance yourself through your state’s commercial exchange (e.g. Obamacare / Affordable Care Act), you can either call your insurance or check your insurance’s online portal (see instructions above).

Medicare

Medicare’s official policy does not include coverage for Zepbound, Wegovy, Saxenda, or any other weight-loss medication. However, you may still be able to access a GLP-1 through an off-label prescription or other means. For example Medicare Part D plans do cover GLP-1s like Ozempic if prescribed for type 2 diabetes. In fact, Ozempic is one of the top 10 Medicare Part D drugs with total gross spending of $2.6 billion in 2021. Additionally as of March 8th, 2024 the FDA approved Wegovy (semaglutide) as a treatment to reduce risk of serious heart problems specifically in adults with obesity or overweight which opens the door for prescriptions of Wegovy for patients with cardiovascular disease.

Medicaid

Coverage for Zepbound under Medicaid differs by state. You can refer to the Eli Lilly directory linked at the bottom of this page to explore your state’s Medicaid preferred medication list and check coverage specifics. If Zepbound isn't covered in your state, consider discussing an appeal with your healthcare provider. Interestingly, while most Medicaid programs typically exclude weight-loss medications, as of July 1, 2023, 16 states had coverage for at least one such medication:

• California
• Connecticut
• Delaware
• Hawaii
• Kansas
• Louisiana
• Michigan
• Minnesota
• Mississippi
• New Hampshire
• Pennsylvania
• Rhode Island
• South Carolina
• Texas
• Virginia
• Wisconsin

Federal Employees Health Benefits (FEHB)

If you're a government employee, coverage for Zepbound can vary greatly depending on your employment level—city, state, local municipality, or federal. For example the OPM requires every Federal Employees Health Benefits (FEHB) to cover at least one GLP-1 weight loss drug in 2025.

VA Coverage‍

‍VA health care will cover obesity management, which means there is a decent chance that Zepbound is covered by your plan. To confirm, contact your local VA provider.

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Step 4: Estimate your likelihood of receiving Zepbound coverage approval

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Key Takeaways
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‍• Your next steps - and chances of approval - will depend on whether Zepbound is on your insurance plan’s formulary.
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• Meeting the FDA’s eligibility requirements for Zepbound is only one criteria reviewed by insurance when determining coverage.
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• Honest Care’s GLP-1 specialists can assist with understanding your likelihood of coverage and compiling evidence to help you get coverage.

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Once you understand your insurance coverage benefits there are three general cases that have the most impact on your likelihood of getting approved by your insurance. Whether Zepbound is on your formulary (list of covered drugs) or is not on your formulary.

Zepbound is on your formulary

If Zepbound is present on your formulary, most insurance plans will likely require a prior authorization or other restrictions for GLP-1 medications before coverage will be approved.

Common clinical and process requirements include:

• Prior authorization: This means your insurance needs to review a request for the medication in order to determine if they’ll cover it. You’ll need to provide some information for review of coverage - common necessary PA information can be found below.
• Tier exception: This means on your plan, Zepbound falls into a higher tier of medication (usually based on whether the medication is brand name or generic, as well as the cost of the medication) and is considered non-preferred. You may need to file a tier exception request, or submit a prior authorization.‍
• Quantity limit: Your plan has a limit on the quantity of medication you can receive over a certain period of time. This may just mean your plan won’t authorize more than the usual dosage in a month’s period. Or it could mean they won’t authorize you to stay on one dosage and will require you to regularly titrate up.‍
• Step therapy: Your plan may require you to try one, some, or all of a predetermined list of other medications commonly used for weight loss before turning to the requested agent. These can include medications such as metformin, phentermine, Qsymia, and Contrave. If your provider believes there are medical reasons you cannot participate in step therapy, they can submit a step therapy exception on your behalf. For many insurance companies, this will be the same form used to submit a prior authorization.
• Enrollment in a “comprehensive weight management program”: While each insurance company has their own rules, a frequently considered factor for determining coverage is whether you participated in organized weight-loss programs (think Weight Watchers, Jenny Craig, Keto) and how much weight you were able to lose as a result of these programs.

Zepbound is NOT on your formulary

If you find out that Zepbound is not a covered medication on your plan’s formulary, don’t panic, there are still options. Your next steps should be to confirm which of the following two categories you fall under to understand your coverage options.

• Non-formulary: In this case your insurance provider has decided to specifically not include Zepbound on your plan’s formulary. In this case, you can seek coverage through an appeal process commonly referred to as a formulary exception. If you’d like a more in-depth discussion surrounding appeals, read our 5 steps to appeal a Zepbound coverage denial.‍‍
• Plan Exclusion: Your employer has decided not to include Zepbound on your plan’s formulary. More specifically, they’ve likely chosen to exclude all weight loss medications. In this case, coverage of Zepbound for the treatment of obesity is unlikely, though we have heard some reports of success with formulary exception requests and denial appeals. In cases like this, we recommend speaking to your employer’s point of contact for insurance questions, and asking for consideration of coverage in the future. If you have one of the comorbidities outlined in Step 2, another option is to speak to your provider about prescribing Zepbound off-label for treatment of another condition, and request coverage from there.

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‍Step 5: Decide on how you’ll get a Zepbound prescription
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Key Takeaways

• Working with your primary care physician (if you have one) can increase your chance of Zepbound approval

• Online, telehealth-based options can also be an option but you want to consider your budget first

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If you’ve taken the above steps and think Zepbound is right for you, next you’ll want to decide what doctor you’ll work with to get a Zepbound prescription. Some considerations:
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• Do you already have a primary care physician? A physician that knows you well is best positioned to advocate on your behalf with your insurance to get coverage for Zepbound. They understand your medical history, have access to your medical records to share with your insurance as needed, and can write an effective Letter of Medical Necessity.
  
• Do online services fit your monthly budget? Online, telehealth-based weight loss clinics offer the benefit of convenience and accessibility to doctors if you don’t have a primary care physician close by or at all. The challenge is that most online services cost $150 or more per month in subscription fees, not including the cost of medications. If you have a total budget of less than $250 a month for accessing Zepbound or another GLP-1, it may make sense to try the traditional, in-person prescription route first.

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Step 6: Submit your personal evidence to your doctor and insurance to improve your chance of Zepbound coverage
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Key Takeaways

• Document your medical and weight history and submit it to you insurance to increase your chance of insurance coverage.

• Honest Care can generate evidence on your behalf through our rapid GLP-1 assessment and report‍

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To increase your chance of accessing a prescription for Zepbound and getting coverage, do your best to compile documentation on your medical and weight history. Share this with your doctor when you discuss your prescription for Zepbound, and if you have a prescription written, ask your doctor to submit this documentation to your insurance to support your case. Some suggestions on what to include:
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• Your participation in organized weight-loss programs: While each insurance company has their own rules, a frequently considered factor for determining coverage is whether you participated in organized weight-loss programs (think Weight Watchers, Jenny Craig, Keto) and how much weight you were able to lose as a result of these programs.
• Your diet and exercise history: Some insurance companies require you to attest to whether you’ve attempted weight loss through calorie restriction and increased exercise previously, and may ask whether you were able to lose a certain amount of weight over the course of 3 to 6 months.
• Your "medication step therapy" history: Before approving coverage for popular GLP-1 medications, some insurance plans first require patients to try lower cost medications. This requirement is referred to as step therapy.
• Comorbidities: Most prior authorizations will ask whether you have any additional weight-related health conditions such as diabetes, hypertension, high cholesterol, or hypothyroidism. For a full list of accepted comorbidities, see Step 2.

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Step 7: If you are denied insurance coverage for Zepbound, submit an insurance appeal
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Key Takeaways

• If you’re denied Zepbound coverage, try appealing the decision with your insurance.

• Write a letter that addresses why Zepbound is right for you and submit it within your appeal.

• Let Honest Care write your appeal letter and gather supporting evidence so you can make your strongest case for insurance approval.

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In the event that your insurance denies coverage for Zepbound, you can try appealing the decision. The insurance appeal process allows you to advocate with your insurance on why Zepbound is necessary for you. To appeal you’ll want to follow this high level process:
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• Understand why you were denied: Call your insurance and ask for the specific reasons why your Zepbound prescription was denied. It may be for the sole reason that Zepbound isn’t covered, but it’s important to understand all reasons. Your insurance is obligated to provide you a written explanation on why you were denied, which should be included within an “Explanation of Benefits”. Ask for this Explanation of Benefits. It should also include specific instructions on how to submit an appeal to your insurance.
• Submit an appeal stating why Zepbound is right for you: Your appeal should include a written letter stating why you should be granted coverage for Zepbound. If possible, ask your doctor to write a Letter of Medical Necessity on your behalf and include it within your appeal. Include your name, policy number, group number and claim/identifier associated with your insurance’s pre-service denial.

ⓘ Learn more about appeals? Read our 5 steps to appeal a Zepbound coverage denial.‍

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Step 8: If you aren’t able to get Zepbound coverage, explore these alternative options

If you aren’t able to get Zepbound covered by insurance, you still have options. Here are paths you can consider:‍

• Consider the coupon: Eli Lilly offers a savings card for individuals with commercial insurance. If your insurance will not cover Zepbound, you may be eligible to receive Zepbound for around $550 per month with the savings card. While this is still a considerable amount, it’s about half of the regular price for Zepbound, and is a bigger savings than Novo Nordisk offers with their Wegovy savings card. Read more on the Zepbound savings card and additional ways to save on Zepbound.
• Pursue Wegovy or Saxenda: As mentioned above, Wegovy and Saxenda are alternative GLP-1s that are also approved for weight loss. If your insurance doesn’t cover Zepbound, it’s still possible they might approve coverage for Wegovy or Saxenda. You may also be able to get coverage for an off-label prescription to Mounjaro or Ozempic.
• Consider “compounding options”: Drug compounding is the process of combining, mixing, or altering ingredients to create a medication tailored to the needs of an individual patient. There are several services that offer compounded Tirzepatide (the active ingredient Zepbound) and compounded Semaglutide (the active ingredient Wegovy and Ozempic). Compounded medications are not technically approved by the FDA, and there can be increased risks in taking medications that aren't approved by the FDA. A benefit of compounding services is that both Tirzepatide and Semaglutide can be acquired at a more affordable price for those without insurance. Compounding services generally cost between $250-$500 month, which includes the cost of medications. We encourage you to speak to your doctor regarding this option.

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