Does Cigna cover Zepbound?
Key highlights
- Cigna’s coverage of Zepbound and other weight loss medications varies by insurance plan.
- For those without Zepbound coverage or with high copays, additional savings may be possible by using the Zepbound Savings Card.
- Prior authorization is typically required for Zepbound coverage with Cigna.
prescription drug manufactured by Eli Lilly and is FDA-approved for chronic weight management for adults with obesity or overweight.. Without insurance coverage, Zepbound costs around $1,000 per month. If you’ve been prescribed Zepbound and are insured through Cigna, you may be wondering if this weight loss medication is covered by your insurance plan.
Insurance coverage for Zepbound typically varies by plan. Most insurance plans don’t cover weight loss medications, including Cigna, and when they are covered, prior authorization is generally required.
If you have prescription drug coverage with Cigna and have been prescribed Zepbound for chronic weight management, read on to find out if your plan provides coverage for Zepbound, how to obtain coverage for the weight loss drug, and options to save on Zepbound if your medication is not covered.
Does Cigna cover Zepbound?
It depends. Coverage varies by plan and some of Cigna’s insurance plans exclude Zepbound from coverage, while other plans cover it with prior authorization before coverage is approved.
If Zepbound is covered by your Cigna insurance plan, the copay (how much you pay out-of-pocket) will also vary by plan and drug tier.
Do I need prior authorization for Zepbound?
Yes, Cigna will typically require prior authorization (also known as precertification or preapproval) before approving coverage for Zepbound. Prior authorization is a process required by insurance plans to verify that the medication is a medical necessity for you and involves your healthcare provider submitting paperwork to support the request for coverage. Your provider may need to ask you some questions so they can complete the paperwork, such as details about your previous attempts to lose weight through diet, exercise, or other medications.
While submitting a prior authorization does not guarantee that your medication will be covered, it will help to increase the chances of approval.
Your healthcare professional will need to document that you meet all of Cigna’s requirements:
- You are at least 18 years old.
- You started making behavioral changes, including a reduced-calorie diet and exercise, at least 3 months before starting Zepbound.
- Before you started Zepbound, your initial body mass index (BMI) was 30 or greater, or 27 or greater if you have at least 1 weight-related condition (such as type 2 diabetes, obstructive sleep apnea, high blood pressure, dyslipidemia, cardiovascular disease, high cholesterol, COPD, metabolic-dysfunction associated steatotic liver disease/non-alcoholic fatty liver disease, polycystic ovarian syndrome, or coronary artery disease).
- You intend on using Zepbound in combination with behavioral changes, including a reduced-calorie diet and increased exercise.
If you meet these four requirements, Cigna may approve your coverage request for up to eight months.
At that time, you will need to submit another prior authorization if you intend to continue treatment with Zepbound and would like to extend the prescription drug coverage. Your provider will need to document that you still meet all of the requirements above and also the new requirements for continuing therapy:
- You have also lost at least 5% of your baseline body weight since you started using Zepbound.
- You can tolerate a Zepbound maintenance dose of 5 mg, 10 mg, or 15 mg once weekly.
If you meet all of the requirements, Cigna may approve your Zepbound coverage for 12 months.
Cigna will not approve coverage if you’re taking any other medications for weight loss or diabetes, including GLP-1 (glucagon-like peptide-1) agonist) medications such as Ozempic.
If your prior authorization request is denied by Cigna, you can try to appeal the decision with the help of your healthcare provider. The denial letter should include details on why you were denied and the steps to appeal the decision. Speak with your healthcare provider for further assistance.
How to check if my Cigna plan covers Zepbound
To check if your Cigna plan covers Zepbound, you can try the following:
- Login to the Cigna member portal to view your plan’s documents and drug formulary. The formulary includes a full list of all medications that are covered by your plan, their drug tier (which includes the copay or out-of-pocket cost), if prior authorization (denoted by “PA” next to the drug name) is required, and other coverage requirements. If Zepbound is not on the formulary, it may not be covered and you can still call your insurance company to be sure.
- Call your insurance company using the phone number on the back of your insurance card.
- Ask your healthcare provider or pharmacist to check your coverage.
- 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 to do if Cigna won’t cover Zepbound
If Cigna doesn’t cover Zepbound, you may have to pay out-of-pocket for the full price of the medication. According to the manufacturer, Eli Lilly, the list price for Zepbound is just over $1,000 per month without insurance. However, you can pay significantly less if you qualify for the Zepbound Savings Card.
If Zepbound isn’t on your insurance plan’s drug formulary, your provider can submit a medical exception request to Cigna requesting that they cover Zepbound for your condition.
If Zepbound is on the drug formulary but Cigna denies the prior authorization for Zepbound, ask your healthcare professional to submit an appeal with supporting paperwork that explains why Zepbound is medically necessary for you. If Cigna denies the appeal and you are left without Zepbound coverage, you can consider several other options:
- Consider Zepbound alternatives: Some insurance plans may cover other weight loss medications with lower copays. Speak with your healthcare provider if there are other weight loss drugs covered by your Cigna plan. These are examples of other weight loss drugs:
- 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.
- Research other insurance plan options: Open enrollment periods (OEP) are typically from November 1 to January 15 in most states. You can consider switching to another insurance plan that covers Zepbound.
Save money on Zepbound without Cigna coverage
If your Cigna healthcare plan does not cover Zepbound, there are several other options for you to save on your out-of-pocket expenses:
- Zepbound Savings Card: Eli Lilly offers a Zepbound Savings Card that reduces the cost of Zepbound for eligible commercially insured patients without any type of government insurance such as Medicare, Medicaid, or other state-sponsored or federal-sponsored health insurance. To qualify, you must have a commercial insurance plan, such as a Cigna health benefits plan through your employer. If your Cigna plan covers Zepbound, you can pay as low as $25 for a 1 or 3-month supply of medication, with a maximum savings of $150 for a 1-month supply, $300 for a 2-month supply, and $450 for a 3 month supply, or $1,800 per calendar year. For individuals with commercial insurance and without coverage for Zepbound, you can pay as low as $650 for a 1-month supply of Zepbound. There is currently no patient assistance program available for Zepbound.
- Generic drug alternatives: Speak with your healthcare provider about potential generic drug alternatives such as orlistat. Currently, there is no generic version of Zepbound available in the United States.
- Prescription discount cards: If you are paying fully out-of-pocket and not using insurance, check out GoodRx, Optum Perks and SingleCare for prescription drug discount cards for Zepbound.
- Health Savings Account (HSA) or Flexible Savings Account (FSA): Check if you can use the funds towards purchasing Zepbound.
- Compounded tirzepatide (same active ingredient as Zepbound and Mounjaro): As Zepbound is currently listed on the FDA Drug Shortages website, you can purchase compounded tirzepatide through the NiceRx Weight Loss Program.
- LillyDirect: Eli Lilly offers the Zepbound single-dose vials in the lower-strength dosages, 2.5 mg and 5 mg directly through LillyDirect.
If you need further assistance, talk with your healthcare provider or benefits administrator.
Bottom line
Cigna coverage for Zepbound depends on your specific insurance plan. If the medication is covered by your plan, prior authorization is typically required. Check your insurance plan’s drug formulary to verify if Zepbound is listed and if prior authorization (“PA”) is required.
If you can’t 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 speak with your healthcare provider about lower-cost Zepbound alternatives including generic drugs like orlistat or compounded tirzepatide.
