Would you want to know why insurance doesn’t cover zepbound? Drawing on my experience, I would advise that the specifics of your particular plan—including your deductible and copay amounts—determine the insurance coverage for Zepbound.
Generally speaking, Zepbound may not be covered by government-funded insurance programs. Zepbound coverage for commercial insurance policies might differ.
If your plan provides coverage for Zepbound, usually prior permission is needed.
Again, drugs more costly or not regarded as “first-line” choices may call for prior permission.
Regarding Zepbound, first-line choices might include alternative, more reasonably priced drugs for weight reduction or diet and exercise.
Your healthcare professional will certify on the prior permission form that you have tried these other choices before and require a more efficient treatment for weight control.
However, that is not all; as you will learn going forward, I will cover more on the topic.
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Now, let’s get started.
Does Insurance Cover Zepbound
While some insurance policies cover the cost of Zepbound and other weight reduction drugs, some do not, and some need previous permission.
State or municipal rules guide what is covered under insurance programs run by the American government, unlike private, commercial insurance (such as plans you obtain through your work or buy on your own)
Medicare: Unless specifically advised for an extra health benefit like reducing the risk of stroke or heart attack, Medicare Part D, the U.S. federal government’s prescription coverage program, does not presently pay the cost of Zepbound or other weight reduction drugs.
Under Medicaid, states decide whether or not to pay for weight loss drugs. Every state maintains a Preferred Drug List (PDL), which lists covered medications.
Ask your doctor about submitting an appeal should your state not cover Zepbound. At least sixteen states covered one or more weight loss medicines under Medicaid as of March 2024.]
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What If My Insurance Won’t Cover Zepbound?
Should Zepbound not be covered by your insurance, you still have choices for lowering your pharmacy costs. As a result:
Programs for Patient Assistance: PAP For those who want financial help, drug companies give PAPs to offer their drugs either at cheap or free cost.
Though it may change, Eli Lilly’s Lilly Cares Foundation does not now list Zepbound as one of the covered drugs.
To find out whether you qualify for any additional financial aid programs, call The Lilly Answers Center Monday through Friday at 1-800-Lilly-Rx (1-800-545-5979)
If you have business insurance, you could qualify for the Zepbound Savings Card, which can drastically lower the Zepbound cost for eligible individuals, as discussed above.
Websites include Drugs.com, OptumPerks, and GoodRx, which provide discount cards for particular pharmacies, which can help you save on Zepbound’s cost.
Should you have a flexible spending account (FSA) or a health savings account (HSA), you could be able to assist with Zepbound payment by using that money.
Zepbound alternatives: Should your insurance not cover Zepbound, it may cover another weight-loss medicine such as Saxenda (liraglutide) or Wegovy (semaglutide).
Although Zepbound can be costly, you have choices to help you pay less out-of-pocket. Discuss your options with your doctor.
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How Much Is Zepbound With Insurance
Should your insurance plan cover Zepbound for persistent weight loss, your out-of-pocket expenses would rely on your particular deductible, benefit coverage, and copay level.
Insurance companies have different coverage policies; hence, the benefits of a patient’s plan vary. To find your plan features and prices, contact your insurance.
Should your commercial (private) insurance cover Zepbound and your doctor write this prescription, it might be more reasonable for you to obtain access utilizing a Zepbound Savings Card provided by Eli Lilly, the manufacturer.
With a 1-month (4 pens) or 3-month (12 pen prescription), qualified commercially insured individuals might spend as little as $25. The copay card only allows you to utilize 13 medication fills maximum each calendar year.
The card’s savings have certain restrictions as well. Maximum annual savings of up to $1,800 per calendar year follow from monthly savings of up to $150 for one-month prescriptions, $300 for two-month prescriptions, or $450 for three-month prescriptions.
Patients with government-sponsored insurance such as Medicare, Medicaid, or Tricare are usually not eligible for copay cards.
Find out from your insurance provider your out-of-pocket expenses before your medications are reimbursed.
Should your annual insurance deductible be for prescriptions, you might have to meet your deductible before any pharmaceutical coverage would begin completely.
Your insurer should pay for some or all of your approved medication after your annual out-of-pocket expenses are paid.
How Much Is Zepbound Without Insurance
Using a free online discount coupon, the price of a supply of four injectable pens that contain a month’s supply of medicine for Zepbound subcutaneous injection is around $1,125.
This price is for a supply of four injectable pens.
You can potentially save money by using the Drugs.com discount card, which is available at the majority of pharmacies in the United States (including Walgreens, CVS Pharmacy, and Walmart), and the Zepbound pricing guide is based on using this card.
Prices are subject to change based on the drugstore that you visit or the coupon that you use online. The prices only apply to clients who pay with cash and are incompatible with insurance policies.
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What If My Insurance Won’t Cover Zepbound
You may be eligible to pay a lower price through Eli Lilly, as low as $550 per month if you have commercial insurance, but your plan does not cover Zepbound.
This discount is available to you if you have commercial insurance. During Monday and Friday, obtain information on any financial assistance programs you might be eligible for.
Inquire with your insurance provider about whether or not your prescription plan covers additional drugs used for weight reduction.
Talk to your healthcare practitioner about these choices to determine whether they may be a suitable replacement for Zepbound if your insurance does not cover this medication.
You may utilize funds from your Health Savings Account (HSA) or Flexible Spending Account (FSA) provided by your work to assist with paying for Zepbound and other medical expenses.
Which Insurance Companies Cover Zepbound
Your insurance plan will determine your Zepbound’s health insurance coverage.
Should you purchase health insurance on the federal marketplace, your plan must include prescription medications and coverage for Zepbound based on the formulary of your insurer.
Prescription medication coverage is not required in employer-sponsored insurance programs.
Furthermore, an employer could choose their insurance provider even when the formulary of another is followed.
Check the PDL of your health insurance plan and contact your business’s benefits coordinator to find out whether Zepbound is covered under your corporate strategy.
Patients with government insurance—programs administered by federal, state, or municipal governments covering some or all of a beneficiary’s health care costs—are unlikely to have Zepbound coverage.
There are some outlays, though:
Medicare does not cover Zepbound; however, patients who have Medigap or Medicare Advantage benefits from a commercial insurance organization might be qualified for treatment.
Medicaid does not cover Zepbound, but it does not forbid individual states from providing coverage. See the recommended medicine list for your state to see if Medicaid, where you live, covers Zepbound.
Under the MOVE! Weight Management Program, veterans undergoing treatment through Veterans Affairs (VA) Health Care might be qualified for Zepbound coverage.
Your weight and the regulations of your local VA institution determine your coverage. Get specifics from your local VA provider.
With previous permission, TRICARE insurance—for service personnel, retirees, and their families—may cover Zepbound.
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Final Thought
Now that we have established why insurance doesn’t cover Zepbound, There is a possibility that you will be required to obtain a prior authorization (PA) before your insurer will fund Zepbound, even if your insurance company does cover the treatment.
In order to complete this procedure, your healthcare professional will need to supply your insurance company with documentation that explains why the prescription you are taking is required for your medical condition.