Does Aetna cover Zepbound? All you need to know

prescription drug manufactured by Eli Lilly for chronic weight management in people with obesity or overweight.

Without insurance coverage, Zepbound costs around $1,000 per month. Insurance coverage for Zepbound typically varies by plan but most Aetna insurance plans will cover the medication with certain conditions.

If you have prescription drug coverage through Aetna and have been prescribed Zepbound for chronic weight management, keep reading to find out if your plan covers Zepbound, how to obtain coverage, and what to do if your coverage is denied.

Does Aetna cover Zepbound?

Yes, Aetna covers Zepbound as a preferred drug. Your coverage for Zepbound depends on the specific coverage details of your Aetna plan including if you’ve already met your deductible.

Health benefits and health insurance plans contain exclusions and limitations. Some Aetna benefit plans may exclude coverage of weight loss medications in their pharmacy benefit and/or health benefits plan.

Aetna Health is comprised of a group of companies (part of the CVS Health family of companies) and coverage can vary by insurance plan. For example, Aetna’s Advanced Control Plan and the Aetna Standard Plan cover Zepbound. When Zepbound is covered by Aetna, it is typically listed under their Preferred Brand (“PB”) drug tier. Prior authorization is typically required before Aetna will provide coverage.

The copay will also vary by plan and drug tier. If Zepbound is covered by your plan and you have a high copay, you may be eligible to pay as low as $25 for a 1-month or 3-month prescription by using the Zepbound Savings Card. If Zepbound is not covered by your plan, you may be eligible to pay as low as $650.

Zepbound is FDA-approved for chronic weight management in obesity (body mass index of 30 or more) or overweight (body mass index of 27 or more) with at least one weight-related condition (such as high blood pressure, type 2 diabetes or high cholesterol) in addition to a low-calorie diet and exercise. Obtaining coverage for Zepbound is limited to its FDA-approved indication.

Do I need prior authorization for Zepbound?

Yes, in most cases, Aetna will require prior authorization (also known as preapproval or precertification) for Zepbound before approving coverage. Prior authorization is a process required by insurance plans to verify that the medication is medically appropriate for you and involves your healthcare provider submitting clinical evidence to support the request for coverage and may require step therapy which involves trying another lower-cost weight loss medication before approving coverage for the more expensive brand name drug.

To determine if your Aetna plan requires prior authorization, check your insurance plan’s drug formulary and see if there is a “PA” next to Zepbound which means that prior authorization is required.

If prior authorization is required by your Aetna plan for obtaining Zepbound coverage, your healthcare provider will need to submit a request to Aetna with paperwork that confirms you meet your insurance plan’s eligibility requirements before coverage is approved. The prior authorization requirements may vary by insurance plan and typically include:

• Prior authorization request submission: Your healthcare professional submits a prior authorization request to Aetna on your behalf.
• Clinical documentation: Your healthcare provider submits documentation that supports your medical necessity for Zepbound according to Aetna’s clinical guidelines and may include documentation of your weight, body mass index (BMI), step therapy, lifestyle modification and/or bloodwork.
• Step therapy: you may also be required to attempt step therapy before Aetna approves coverage for Zepbound. Step therapy requires that you try at least one lower-cost FDA-approved medication that treats the same condition. If your Aetna plan requires step therapy, your healthcare provider may need to document that you tried and failed to use a lower-cost alternative such as metformin and it didn’t work for you.
• Review and approval: Aetna will review and either approve or deny the request. If approved, Zepbound will be covered by your plan with quantity and day supply limits.

Prior authorization requirements may change over time, so you should check your most recent Aetna plan documents for an up-to-date description of benefits, limitations, exclusions and conditions of coverage. You can also call Aetna’s precertification team at 1-855-582-2025 (TTY: 711) for more information.

If your prior authorization is denied, you can try to appeal the decision. The denial letter will include details on why you were denied and the steps you can take when requesting an appeal of the decision. Talk to your healthcare provider for further assistance.

How to check if my Aetna plan covers Zepbound

To find out if your Aetna plan covers Zepbound, you can follow these steps to check your Aetna plan documents for coverage details, deductible and copays:

1. Log in to your Aetna member website using your member ID and password.
2. Navigate to the pharmacy or prescription drug section of your account.
3. Use the drug lookup tool to search for Zepbound. Select the current year under the “Choose a plan year” drop-down menu and select your plan under the “Choose a plan” drop-down menu. If you are enrolled in the Medicare Prescription Drug Plan (PDP) with Aetna Inc., you can access the drug formulary here.
4. Review coverage information, including any requirements or limitations for Zepbound.

Alternatively, you can:

• Call the Aetna member services phone number on the back of your Aetna member ID card or contact Aetna by live chat or email.
• Ask your healthcare professional or pharmacist to check your coverage.
• Review your insurance plan’s formulary or drug list, which is often available on Aetna’s website.
• Call 1-800-LillyRx (1-800-545-5979) to talk to an agent from the manufacturer, Eli Lilly, who can help verify your coverage details for Zepbound.
• Check coverage details on the Zepbound website.

What if Zepbound isn’t covered in my Aetna plan?

If Zepbound isn’t covered by your Aetna plan, you or your healthcare provider can submit a request for a medical exception if:

• You have a health condition that may seriously jeopardize your life, health or ability to regain maximum function.
• You are undergoing a current course of treatment using a non-covered medication.

To request a medical exception, you or your healthcare provider can:

• Call Aetna’s precertification team at 1-855-582-2025, or;
• Fax your request to 1-855-330-1716, or;
• Mail a written request to Aetna PA, 1300 E. Campbell Road, Richardson, Texas 75081.

Aetna will contact you or your healthcare provider with a coverage decision within 24 hours of receiving the request.

What to do if Aetna won’t cover Zepbound

If Zepbound isn’t on the drug formulary or if Aetna denies the request for a medical exception, read on for tips on what else you can do.

If Aetna denies the prior authorization for Zepbound, ask your healthcare professional to submit an appeal with additional information that explains why Zepbound is medically necessary for you. The denial letter from Aetna will include details on why your request didn’t meet clinical guidelines and you can ask for a review between your healthcare provider and Aetna’s medical director. The denial letter will also explain the steps for requesting a formal appeal of the decision.

If Aetna denies the appeal and you are left without Zepbound coverage, you can consider several other options:

1. Consider Zepbound alternatives: Some insurance plans may not provide coverage for Zepbound but may cover alternative weight loss medications. Discuss with your healthcare provider if there are other weight loss drugs covered by your Aetna plan which may include:
   • Saxenda
   • Wegovy
   • Qsymia
   • Orlistat or other generic drugs
2. Consider paying for the medication out-of-pocket: If Zepbound is the best treatment option, you may choose to pay out-of-pocket without insurance coverage. However, be aware that the cost can be significant. Without insurance coverage, the list price of Zepbound is around $1,000 per month. However, if eligible, you may be able to pay as low as $650 for a 1-month prescription when using the Zepbound Savings Card if you are commercially insured with Aetna but without insurance coverage for Zepbound.
3. Explore other insurance plan options: During open enrollment periods (OEP), which typically begins November 1 and ends January 15 in most states, you can consider switching to another Aetna plan that covers Zepbound or exploring other insurance companies that provide coverage for Zepbound.

Save money on Zepbound without Aetna coverage

If you are unable to obtain Aetna coverage for Zepbound, here are some other ways to reduce your out-of-pocket expenses:

1. Use manufacturer savings cards: Eli Lilly offers a Zepbound Savings Card that can help reduce the cost of Zepbound for eligible commercially insured patients. Individuals who are enrolled in government insurance programs such as Medicare, Medicaid etc. are excluded.
2. Consider generic drug alternatives: While there isn’t a generic or biosimilar alternative to Zepbound available on the market yet, your healthcare professional may be able to prescribe a lower-cost generic drug alternative.
3. Compare prices with prescription discount cards: Check out discount cards offered by companies like GoodRx and SingleCare may offer discounts on Zepbound without insurance.
4. Health Savings Account (HSA) or Flexible Savings Account (FSA): You might be able to use the funds towards buying Zepbound.
5. Compounded medications: You can consider compounded tirzepatide which has the same active ingredient as Zepbound and Mounjaro, and is available through the NiceRx Weight Loss Program.
6. Zepbound 2.5 mg and 5 mg vials available from LillyDirect: Eli Lilly offers single-dose vials in the lower-strength dosages 2.5 mg and 5 mg directly from LillyDirect.

If you need further assistance, talk with your healthcare provider or benefits administrator.

Bottom line

While many Aetna plans cover Zepbound for chronic weight management once the plan deductible has been met, coverage details vary by plan and it’s important to check your plan documents or speak to Aetna to verify coverage.

Prior authorization is typically required by most Aetna plans. Check your insurance plan’s drug formulary to find out if Zepbound is covered and if prior authorization is required before coverage is approved by logging into the Aetna member website or calling the number on the back of your Aetna card. You can also contact Eli Lilly to verify your coverage details.

If you are unable to obtain insurance coverage for Zepbound, or if your copay is too high, the Zepbound Savings Card can provide additional savings, if eligible. You can also consider alternative medications including lower-cost generic drugs or compounded tirzepatide, if your healthcare provider determines they are medically appropriate for you.