[Updated: June 20, 2024] Which insurance covers Zepbound ⬝ BCBS, Cigna, United Healthcare, Optum, CVS, Medicare, Medicaid ⬝ Zepbound insurance denials ⬝ Zepbound without insurance
ⓘ Denied insurance coverage for Zepbound? Honest Care can help you appeal to get Zepbound covered.
Zepbound is not covered? Skip to Step 2. If Zepbound is covered, skip to Step 3.
While the majority of employer-sponsored insurance covers GLP-1s like Mounjaro and Ozempic, only about a quarter of employers cover GLP-1s like Zepbound, Wegovy or Saxenda for weight loss according to a 2023 survey. If your employer offers a ‘self-insured plan’, then whether Zepbound is covered is the decision of your employer. If your employer offers pre-designed insurance plans through a ‘group market’, coverage for Zepbound will depend on the plans your insurer offers your employer. In either case, your HR department should be able to guide you on Zepbound coverage.
Whether Blue Cross Blue Shield or BCBS covers Zepbound depends on which BCBS company you are insured under, the type of Blue Cross plan you have (through private employer, FEP, Medicaid, Medicare or Marketplace), and the Zepbound policy of your specific plan. To understand if Blue Cross covers Zepbound, find your BCBS provider within this official list of Blue Cross Blue Shield companies and check your plan’s policy.
In July 2024, Optum Rx added Zepbound to its Prior Authorization formulary, meaning Optum Rx coverage for Zepbound is possible but requires prior authorization. Understanding whether Optum cover Zepbound requires you to review your specific plan policy on Zepbound. To understand your policy, try contacting the Optum’s prior authorization department by calling 1-800-711-4555 or using Optum's online portal. United Healthcare's coverage of Zepbound will match the Optum Rx policy, provided Optum Rx manages the pharmacy benefits of your United Healthcare plan.
Express Scripts, which is owned by Cigna, announced that Express Scripts would cover Zepbound starting December 15, 2023 by adding Zepbound to its preferred formulary for commercial plans. Cigna's formulary policy on Zepbound will match Express Scripts policy, provided Express Scripts manages your the pharmacy benefits in your Cigna plan. Like all commercial insurance, your coverage for Zepbound depends on your specific plan. For coverage information on your plan, log into Express Scripts online portal to check on Zepbound coverage.
Coverage for Zepbound is very limited under insurance plans purchased through marketplace exchanges (Obamacare). However, unlike government insurance plans, commercial plans do allow you to use the Zepbound coupon.
Unfortunately Medicare does not cover Zepbound as apart of Medicare’s broader decision to exclude coverage for all weight loss medications. If you are covered through Medicare and have been diagnosed with a heart condition or at risk of heart attack or stroke, you may be able to get coverage for Wegovy. If you are diagnosed with diabetes or are at high risk of developing Type 2 diabetes due to presence of metabolic syndrome, you might also be able get Medicare coverage for Ozempic or for Mounjaro, which is the same medication as Zepbound (tirzepatide) but is approved for the treatment of diabetes.
Our latest review indicates that Medicaid does not cover Zepbound in any state so far. That said, sometimes Medicaid programs will cover medications even if they are not listed on their drug formulary. The following 10 states offer Medicaid coverage for Wegovy, suggesting they may be more likely to cover Zepbound as well: California, Delaware, Massachusetts, Michigan, Minnesota, Mississippi, New Hampshire, Pennsylvania, Rhode Island, Virginia. To check Zepbound coverage under your state Medicaid program, find the ‘I have insurance through Medicaid’ section of Eli Lilly’s website.
If you find out that Zepbound is not a covered medication on your plan’s formulary, your next steps should be to confirm which of the following two categories you fall under.
This indicates not include Zepbound on your plan’s formulary or that Zepbound falls into a higher tier of medication and is considered non-preferred. If your insurance covers Wegovy or Saxenda, this likely means that Zepbound is ‘non-preferred’. To get Zepbound covered, you will likely need to request a ‘tier exception’ within your prior authorization request for Zepbound.
This means that no weight loss medications are covered by your insurance, including Zepbound as well as Wegovy, Saxenda, Qsymia and Contrave. If your plan is your employer, then your employer likely has chosen to exclude all weight loss medications. More on this below.
If your employer does not provide insurance coverage for weight loss medications including Zepbound, it is critical that you advocate that this policy be changed going into your next enrollment period. We dive deeper into how to fight weight loss plan exclusions here.
Explain why coverage for Zepbound is a critical benefit for you and your colleagues. To make it easy, we’ve done the legwork and drafted a comprehensive sample letter that you can download and submit to your employer’s HR department. Be sure to include your name at the bottom of the letter.
The more people you can get in on the action, the better. And we’ve got you covered here, too. If you feel comfortable reaching out, you can send this PDF to any coworkers you feel may want to help advocate for coverage of weight loss medications on your company’s health plan. Be sure to send the employer letter to them as well.
If Zepbound is on your insurance’s drug list, it means your insurance will cover Zepbound on your behalf provided that you meet specific requirements. To determine your Zepbound coverage, you will be required to request Prior Authorization for Zepbound from your insurance before coverage will be approved. More information on Zepbound prior authorization is available in this guide.
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, Heart disease, Dyslipidemia, GERD, High cholesterol, Hypertension, Metabolic syndrome, Non-alcoholic fatty liver disease (NAFLD), Obstructive sleep apnea (OSA), Prediabetes, Type 2 diabetes (T2D), and Polycystic ovarian syndrome (PCOS).
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. This guide offers detailed information on step therapy for Zepbound.
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.
In the event that your insurance denies coverage for Zepbound, you can try appealing the decision. Appeals allow you to tell your insurance why Zepbound is necessary for you. For in-depth information review the 5 steps to appeal a Zepbound coverage denial.
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.
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.
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. If your commercial insurance drug plan covers Zepbound, you could pay as little as $25. This copayment applies to a 1-month, 2-month, or 3-month prescription of Zepbound. Read more on the Zepbound savings card and additional ways to save on Zepbound.
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.
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 tirzepatide generally cost between $250-$500 month, which includes the cost of medications. We encourage you to speak to your doctor regarding this option.
If you were denied coverage for Zepbound, you have the right to submit an appeal letter explaining why Zepbound should be covered. Appeals are a free method to fight for coverage and can help reduce the long term cost of Zepbound by thousands of dollars if you win.
According to a study analyzing data from several U.S. states, patients who appealed directly to their insurance provider (an internal appeal) experienced a success rate between 39-59%.
If you were denied coverage for Zepbound, Honest Care can help. Take our 3-minute assessment to learn how.
We believe every insurance denial should be appealed and every patient should fight for access to the best treatments, because access to great healthcare is a human right.
Insurance companies purposely make this process convoluted and difficult to understand in order to deter decision challenges and protect their bottom line. That’s where we come in. We’re bridging the gap between insured individuals and their access to needed medications by creating a free customized insurance appeal letter. We’ll do all the hard work for you - you just need to include a few small edits, then you can send your appeal letter to your insurance provider through their outlined appeal process.
We believe every insurance denial should be appealed and every patient should fight for access to the best treatments we’ve made generating a strong appeal letter free.
We also offer paid services to access our team of GLP-1 experts. If you are not satisfied with our team's services, email our support team at support@findhonestcare.com and we will be happy to remedy any issues. You can also request a refund within 60 days of purchase of our services so long as your appeal hasn't been submitted to your insurance. Once our appeal packet has been submitted to your insurance, we will no longer issue refunds. Refunds are processed to the original payment method within 5 to 10 business days.
We help patients fight insurance coverage denials so they can get access to the medications and treatments they deserve. We currently specialize in insurance coverage denials for Ozempic, Mounjaro, Wegovy and Zepbound.
If you are denied coverage for Ozempic, Mounjaro, Wegovy or Zepbound, Honest Care can help fight your denial by submitting an ‘appeal’ to your insurance. An appeal is a formal request to your health insurance company to overturn their denial and grant coverage on your behalf. An appeal generally consists of a formal letter, addressed to your insurance, explaining why a medication should be covered on your behalf and why your insurance’s initial denial should be overturned.
You have the right to appeal to your insurance’s coverage denial. Honest Care simplifies the appeals process by writing an appeal letter and supporting documents on your behalf making your best arguments for medication coverage, following your completion of our proprietary GLP-1 denial assessment.
If your insurance denied coverage for Ozempic, Mounjaro, Wegovy or Zepbound, you have the legal right to ask your insurance to reconsider the coverage denial by sending an ‘appeal’. Unfortunately coverage denials too often go unchallenged. A study from September 2023 found that 69% of people who were denied coverage by their insurance didn’t know they could appeal, and 85% of people never tried to appeal.
We believe it always makes sense to appeal. Here is why:
Appeals work: According to a study analyzing data from several U.S. states, patients who appealed directly to their insurance provider (an internal appeal) experienced a success rate between 39-59%.
Denials are often issued by mistake: A computer almost always makes the initial decision to deny medication coverage. This results in denials that don’t actually consider your personal health situation or denials made by mistake. In the case of Ozempic, Mounjaro, Wegovy and Zepbound, incorrectly entered information about your BMI, labs including A1c, your health conditions and diagnoses, your medication history and current medication use can all lead to an automatic denial. When you appeal, your information is reviewed by a real person.
Doctors review appeals, not computers: Having a doctor consider your unique circumstances makes submitting an appeal a powerful process for overturning denials getting covered.
You deserve the best care: You have the legal right to fight the treatment you need. As a part of the Affordable Care Act, all health insurance plans are required to allow their members to appeal their coverage decisions. This spans all insurance coverage - whether you are insured through your employer, purchased an insurance plan through your state marketplace, or are insured through a government program like Medicare or Medicaid.
We currently offer appeal services for Ozempic, Mounjaro, Wegovy and Zepbound. After purchasing Honest Care and completing your online denial assessment, you can expect to receive your appeal letter within 2 business days.
1. Online denial assessment: Complete the online assessment at your convenience that gather all the necessary appeal evidence for your insurance. The assessment reviews your medication history, including any GLP-1s, weight loss or diabetes medications you have taken, your health conditions and diagnoses, your past weight loss, diet and exercise attempts, and details on your insurance coverage and denial.
2. Case evaluation & appeal strategy: One of our dedicated appeal specialist will review your assessment and insurance denial and identify your best appeal arguments for coverage. This will include an evaluation of your medication history, medical diagnoses, weight loss attempts and clinical research studies that strength your appeal case.
3. Appeal letter & supporting documents: Your assigned appeal writer will compose a professional appeal letter addressing your denial reason and detailing your case for coverage. We’ll create a supporting evidence report that further justifies your appeal letter, to send your insurance along with your appeal.
4. Specialist Consultation & Support: After you receive and review your appeal letter & evidence, your dedicated appeal specialist will be available to answer your questions. They will be available to make updates to your appeal, if required. You will also have the option to schedule a phone or video call at a time of your convenience to you speak to your dedicated appeal specialist.
5. Send your appeal: You can submit your appeal yourself or have your doctor submit your appeal on your behalf. Most insurance companies accept appeals by mail or fax. Instructions on how to submitted appeal will be included within the written explanation on why you initially denied medication coverage, sent at the time at you were denied.
An insurance appeal is a formal request you make to your insurance company, asking them to reconsider a decision about your claim. This could be when they've denied your claim, not paid enough, or made a decision you disagree with. The appeal is your chance to argue your case, showing them why their decision should be different. It involves submitting a well-structured letter, along with any supporting evidence like medical records or repair estimates, to make your case stronger.
An insurance appeal letter is your way of asking the insurance company to reevaluate a decision, such as a denied claim. It's essentially your argument in writing, explaining why you believe their decision should be different. This is a common document patients can use to advocate for themselves with their insurance to cover their medical costs even prior to being denied for a treatment.
This letter will include your policy details, specific decision you disagree with, and provide solid reasons and evidence (like weight loss efforts, past and present medications, labs, receipts etc) for your appeal. The letter should be clear, concise, and respectful, ending with a specific request for what you want your insurance to do.
You can submit an appeal letter directly to your insurance or through your health care provider as part of your insurance appeal process.
Insurance supporting evidence is the documentation or information you provide to back up your claim or appeal with your insurance company. It's the proof that supports your case, like medical history, diet and exercise efforts, medication history, or relevant medical studies. This evidence is crucial because it shows the insurance company why they should approve your claim or reconsider a decision they've made.
We provide 3 types of supporting insurance evidence.
(1) Appeal Evidence - is the information you provide when you disagree with your insurer's decision about a claim or coverage. This could include detailed medical records, letters from your doctor explaining the necessity of a treatment, or information about how a treatment is standard for your condition. This evidence is crucial for challenging a denial or underpayment of a claim. Our role is to help you gather and present this evidence effectively, ensuring it clearly supports your need for the treatment or service claimed.
(2) Prior Authorization Evidence - is required when your health plan needs you to get approval before it covers certain medications or procedures. This evidence typically includes medical records, lab results, and a detailed rationale about why this specific medication or procedure is necessary for your condition. Our service involves assisting you in compiling comprehensive and relevant documentation to justify the medical necessity, aiming to secure approval from your insurance company for the required treatment.
(3) Step Therapy Exclusion Evidence - is used when you need to bypass the 'step therapy' protocol of your insurance plan. This protocol usually requires trying less expensive treatments before more costly ones are approved. Exclusion evidence might consist of medical records showing previous treatment attempts and failures, clinical data indicating why standard treatments are unsuitable or harmful for you, and detailed explanations about the necessity of the specific, often more expensive, treatment. We help you collect and organize this evidence to make a compelling case to your insurer that the standard step therapy process is not appropriate for your situation, thereby aiming for an exemption.
Working with your regular doctor can increase your chance of insurance coverage in several ways, including:
Yes - your Honest Care Report can be submitted to any doctor, including doctors working with online, telehealth-based GLP-1 clinics. Taking the Honest Care Assessment before engaging with a telehealth services presents several advantages, including helping you save money.
By using Honest Care before engaging with a telehealth company, you’ll find out how likely you are to get a GLP-1 prescription and will receive guidance on any recommended steps to take before your GLP-1 appointment. This can save you money by avoiding paying subscription fees until you’re fully prepared for your telehealth appointment.
There are nearly 10 GLP-1 medications available in the United States. Currently three of those medications, Zepbound®, Wegovy® and Saxenda®, are FDA-indicated for weight-loss assistance. The FDA indicates that people with a BMI ≥ 30 kg/m2 OR people with a BMI ≥ 27 kg/m2 who have been diagnosed with at least 1 weight-related condition are eligible for GLP-1s.
All other GLP-1 medications, including Ozempic® and Mounjaro®, are currently FDA-indicated for people diagnosed with Type 2 diabetes.
While FDA-guidelines are critical for understanding GLP-1 eligibility, there are a number of other factors to consider for determining GLP-1 eligibility.
Additional eligibility criteria that Honest Care takes into account include:
Prior Authorization (PA) is a process run by insurance plans to determine how necessary a medication is. Most insurance plans require Prior Authorization (PA) before approving coverage for GLP-1s.
After your GLP-1 prescription is written, your insurance plan will notify your doctor if a PA is required and ask your doctor for additional documentation on why your medication is necessary.
If a PA is required, your insurance plan will ask your doctor to submit detailed information on your diet and exercise history, your past weight loss attempts, weight loss medications you previously tried, and any unique challenges that you face that make a GLP-1 medically necessary.
The Honest Care Report includes evidence requested by most insurance plans and can be submitted to your insurance during the PA process. During your appointment, your doctor can attach your Honest Care Report to your health record so it is submitted as supporting evidence to your insurance if Prior Authorization is required.
