Is Zepbound covered by insurance?

The weight loss drug Zepbound (tirzepatide) entered the world of medication-managed weight loss in late 2023. If you’re wondering, is Zepbound covered by insurance, you’re in the right place.

In this post, we cover:

• What Zepbound (tirzepatide) is and who can take it
• How much Zepbound costs with no insurance
• How much Zepbound costs with insurance 
• How to understand insurance coverage for Zepbound
• Which insurance companies cover Zepbound
• Is there a more affordable generic version of Zepbound

What is Zepbound (tirzepatide) and who can take it?

Zepbound is an injectable weight loss medication. In November 2023, its manufacturer, Eli Lilly, got it approved by the U.S. Food and Drug Administration (FDA) for use in adults with a body mass index (BMI) of 30 or greater, or 27 or greater with a weight-related health condition, like high blood pressure, type 2 diabetes, or high cholesterol. It’s used as part of a medically-supervised approach to weight loss alongside a lower calorie diet and exercise. 

The active ingredient in Zepbound is tirzepatide. It’s a dual agonist medication that mimics glucagon-like peptide-1 (GLP-1) and gastric inhibitory polypeptide (GIP) hormones, which helps control blood sugar levels and makes people feel fuller, so they eat less and lose weight and body fat. Tirzepatide was initially FDA-approved under the brand name Mounjaro to help lower blood sugar in people with type 2 diabetes. 

In clinical trials for Mounjaro, participants lost weight while taking tirzepatide. That finding led Eli Lilly to seek approval to market tirzepatide for weight loss as Zepbound.

While consumer reviews of Zepbound are generally positive, clinical trials paint a glowing picture. In one tirzepatide trial for obesity, participants lost up to 20.9% of their body weight in 72 weeks with those on a higher tirzepatide dosage losing the most. Note that Zepbound isn’t intended for cosmetic weight loss due to potential serious Zepbound side effects.

How much does Zepbound cost with no insurance?

If you’re interested in using Zepbound for your weight loss, it does have a cost. Without health insurance, what you pay at the pharmacy, which is the retail cost of Zepbound is $1,126 per month regardless of dose, according to drugs.com. If you pay out of pocket, you can expect to pay about $13,500 for Zepbound over the course of a year. 

Be aware that once you start treatment with Zepbound, you’re likely in it for the long haul as research on maintaining weight loss shows that patients tend to regain weight when they stop taking it. 

How much does Zepbound cost with insurance?

Whether Zepbound is covered by insurance depends on your provider and specific plan. If your insurance provider covers Zepbound, your out-of-pocket cost depends on your drug copay and, possibly, your deductible. It’s possible you’ll only pay your drug copay from day one. However, if your insurance plan requires you to meet a deductible before your copay takes effect, you might pay full price until you reach your deductible. 

Your drug copay depends on the formulary (list of covered prescription drugs) and tier that your insurance company puts Zepbound in. More on that in the next section. Reach out to your insurance provider to confirm coverage for Zepbound and your out-of-pocket costs. 

It’s possible to pay for some or all of your cost for Zepbound, including your drug copay, using either your health savings account (HSA) or flexible spending account (FSA). These accounts let you set aside pre-tax dollars to use for qualified medical expenses later. In order to use your HSA or FSA to pay for Zepbound, your healthcare provider will have to submit a Letter of Medical Necessity justifying your use of the medication.  

If you have commercial insurance, you may be able to use the Eli Lilly’s Zepbound Savings Card program. If Zepbound is covered by your insurance plan, the savings card lets you get a 1-, 2-, or 3-month supply of Zepbound for $25. If Zepbound isn’t covered, you can still use the savings card to get your prescription for as low as $550 a month. Note that some restrictions apply. 

Understanding insurance coverage for Zepbound

Zepbound has been on the market less than a year, which means your insurance provider may not have added it to their preferred drug list (PDL), also known as a formulary, yet. If it hasn’t, reach out to your employer’s Human Resources department or benefits coordinator and ask if Zepbound can be added to your coverage. 

If your insurance provider does cover Zepbound, you’ll likely need a prior authorization (PA) before your insurance will cover it. This process requires your healthcare provider to submit paperwork to your insurance company explaining that your use of the medication is medically necessary. A detailed Prior Authorization Resource Guide is provided on the Eli Lilly’s Zepbound website to help you and your provider navigate the process.

Once your Zepbound prescription is approved for insurance coverage, your out-of-pocket cost depends on the tier your insurance company’s formulary places Zepbound in. In a formulary, prescription drugs are assigned a tier from 1 to 5 based on medication type or usage. Each tier has a defined out-of-pocket cost that you’re responsible for paying in order to get your prescription, and higher tiers typically have higher copays. It looks like most insurers are putting Zepbound in tier 3, based on reports for Mounjaro. Contact your insurance provider to verify which tier Zepbound is in and what your monthly copay will be.

Which insurance companies cover Zepbound?

Health insurance coverage for Zepbound depends on your insurance plan. If you get your insurance through the federal marketplace, your plan is required to cover prescription drugs and coverage for Zepbound depends on your insurer’s formulary.  

Employer-sponsored insurance plans don’t have to offer prescription drug coverage. And an employer may not follow the insurance company’s formulary, but pick its own. Check your health insurance plan’s PDL and reach out to your employer’s benefits coordinator to verify whether Zepbound is covered under your company’s plan.

Patients with government insurance (for example, programs run by federal, state, or local governments that cover some or all of a beneficiary’s health care costs) aren’t likely to have Zepbound coverage. However, there are some exceptions:

• Zepbound isn’t covered by Medicare, but patients who receive Medigap or Medicare Advantage benefits through a private insurance company may be eligible for coverage.
• While Medicaid doesn’t cover Zepbound, it doesn’t block individual states from offering coverage. Check your state’s preferred drug list to determine whether Zepbound is covered by Medicaid where you live. 
• Veterans receiving care through Veterans Affairs (VA) Health Care may be eligible for Zepbound coverage under the MOVE! Weight Management Program. Coverage depends on your weight and the policies of your local VA facility. Reach out to your local VA provider for details. 
• TRICARE insurance, which is for military personnel, retirees, and their families, may cover Zepbound with a prior authorization. 

Is there a more affordable generic version of Zepbound?

There isn’t a more affordable or generic version of Zepbound for weight loss available today. However, compounded tirzepatide may provide savings if it’s right for you. You can get tirzepatide from a compounding pharmacy for as little as $350.

Compounding pharmacies use pharmaceutical-grade active ingredients to create custom medications that are tailored to meet individual patient needs. You could choose compounded tirzepatide due to cost, supply shortages, personal preference, allergies, and added ingredients to improve effectiveness and minimize side effects. 

Talk to your healthcare provider if you’re considering compounded tirzepatide as an alternative to Zepbound. They may refer you to a reputable U.S.-based compounding pharmacy or suggest other prescription weight loss alternatives.

Key takeaway

Zepbound (tirzepatide) is an injectable weight loss drug that was FDA-approved in 2023. It’s a long-term use medication that you can expect to spend about $13,500 on each year, if you don’t have health insurance that covers it. 

If Zepbound isn’t on your insurance provider’s list of covered medications, contact your employer’s benefits department. Prior authorization is likely needed in order for your insurance provider to cover Zepbound. Once you have approval, your out-of-pocket cost with insurance will depend on your specific plan, drug copay, and deductible. 

Zepbound isn’t covered under most government insurance plans. While there are some exceptions, government beneficiaries are expected to pay the retail cost or find a covered alternative for weight loss. 

Currently, there isn’t a more affordable generic version of Zepbound. While compounded tirzepatide should work similarly to Zepbound, it hasn’t undergone FDA-testing and may have added ingredients. Talk to your healthcare provider before taking compounded tirzepatide or if you’re seeking a more affordable alternative to Zepbound. 

Get a prescription for Zepbound from a provider on Klarity

Creating a personal medical weight loss program that includes weight loss medication is easy. The Klarity platform can connect you with a licensed healthcare professional who specializes in chronic weight management. Your provider can help you determine whether Zepbound or another weight loss medication is best for your weight loss journey. Get started and find a weight loss provider on Klarity today!

The information provided in this article is for educational purposes only and should not be construed as medical advice. Always seek the guidance of a qualified healthcare professional with any questions or concerns you have regarding your health.

How we reviewed this article: This article goes through rigorous fact-checking by a team of medical reviewers. Reviewers are trained medical professionals who ensure each article contains the most up-to-date information, and that medical details have been correctly interpreted by the author.