Does United Healthcare cover Zepbound?

Zepbound (tirzepatide) is a relatively new glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) weekly subcutaneous prescription medication for people with obesity or overweight. Many Americans rely on this drug to help them lose weight and keep it off. However, as a brand name drug without a generic alternative available, it may be more expensive than other weight loss drugs and a cost burden for people without insurance coverage.

Coverage typically varies by plan. Most insurance plans won’t cover weight loss medications and when covered, prior authorization is usually required. The specific policies depend on your prescription drug benefit plan and you can check with your plan provider directly to verify coverage and cost-sharing specifics including the copay you should expect to pay out-of-pocket.

Without prescription drug insurance coverage, the list price for Zepbound is over $1,000 for a 4-week supply of medication. However, the actual price you pay will depend on which pharmacy you purchase from and if you are eligible for the savings card.

If you’ve been prescribed Zepbound and are insured through United Healthcare (UHC), you may be wondering if this weight loss medication is covered by your insurance plan. Continue reading below to learn more about United Healthcare’s coverage of Zepbound, what steps you can take to find out if this medication is covered, and other savings options in case you are unable to obtain coverage.

Does United Healthcare cover Zepbound for weight loss?

It depends on your plan provider and whether it includes coverage for weight loss medications including Zepbound.

Coverage varies by plan and some of United Healthcare (UHC)’s insurance plans exclude Zepbound from coverage, while other plans may cover Zepbound while requiring prior authorization before approving coverage. It’s up to the individual plan provider to decide on whether they’ll cover weight loss drugs including Zepbound.

You’ll need to have prescription drug coverage and coverage will depend on whether Zepbound is listed on the prescription drug list (PDL), also known as a drug formulary, and the copay will depend on the listed drug tier. Drugs listed in the highest tier (Tier 4) will have the highest copay, and drugs listed in the lower tier (Tier 1) will have the lowest copay.

Your coverage and associated costs may vary based on your specific insurance plan. You can contact United Healthcare or your employer’s benefits administrator for the most up-to-date and accurate information.

Coverage for Zepbound may have certain limits and requirements, such as:

• Prior authorization: Your healthcare professional will need to submit paperwork that explains why Zepbound is a medical necessity for your health condition.
• Quantity limits: There may be restrictions on the amount of Zepbound you can receive at a time which may limit how much medication you can receive with each refill.
• Step therapy: You may be required to try and fail at least one other lower-cost alternative medication before approving coverage for Zepbound.

Do I need prior authorization for Zepbound?

Yes, in general, United Healthcare will require prior authorization before approving coverage. Prior authorization involves getting pre-approval from UHC before coverage is approved under your health plan. This process helps UHC confirm that the medication is medically necessary, meets its coverage criteria, and is the most effective treatment for the patient.

UHC’s prior authorization often applies to specialty drugs and high-cost medications such as Zepbound.

To find out if your United Healthcare (UHC) plan requires prior authorization, check the most recent prescription drug list (PDL) or drug formulary. If there’s a “PA” next to Zepbound, that means that you are required to submit a prior authorization before coverage is approved.

If prior authorization is required, your healthcare professional will typically submit documentation to UHC that justifies the use of Zepbound for your medical condition.

The prior authorization requirements may vary by insurance plan and typically include:

• Request submission: Your healthcare professional submits a prior authorization request to Aetna on your behalf.
• Clinical documentation: Your healthcare provider submits documentation that justifies that Zepbound is a medical necessity for you and meets UHC’s clinical guidelines and may include documentation of your age, weight, body mass index (BMI), step therapy, and/or lifestyle modification. 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 United Healthcare (UHC)’s requirements:
  • You are at least 18 years old.
  • You will use the medication in combination with behavioral changes, including a reduced-calorie diet and exercise, at least 3 months before starting Zepbound.
  • Your body mass index (BMI) is 30 or greater, or 27 or greater if you have at least 1 weight-related condition (such as type 2 diabetes, obstructive sleep apnea, hypertension, dyslipidemia, etc.).
  • You intend on using Zepbound in combination with lifestyle changes like a reduced-calorie diet, exercise, and behavioral support.
• Step therapy: you may also be required to attempt step therapy before UHC approves coverage. Step therapy is a requirement that you have tried and failed at least one lower-cost FDA-approved medication for your condition.
• Review and approval: UHC will review and approve or deny the prior authorization request. If the request is approved, UHC will provide Zepbound for up to six months with quantity and day supply limits.

Prior authorization requirements can change at any time so it’s important that you should check your up-to-date UHC plan documents for the most recent description of benefits, limitations, exclusions and conditions of coverage. You can also call United Healthcare directly to verify coverage and requirements.

If your prior authorization request is denied, speak with your healthcare provider. You can try to appeal the decision. The denial letter should include details on why your request was denied and the steps to appeal the decision.

How to check if my United Healthcare plan covers Zepbound

Here are some potential ways to check if Zepbound is covered by your UHC plan:

• Check your insurance plan’s formulary by reviewing the plan documents or prescription drug list (PDL) for your plan. Search for Zepbound to see its coverage status.
• Contact United Healthcare’s customer service directly by calling the phone number on the back of your United Healthcare member ID card and ask to be connected with someone who can help verify your prescription drug coverage. The pharmacy benefits phone number may be on the back of your member ID card as well. Be ready to provide your member ID for faster service.
• Login to the United Healthcare member portal to view your prescription benefits. The account dashboard has a section for prescription or pharmacy benefits. You can search for Zepbound to see whether your plan covers it, and if so, whether a prior authorization (denoted by “PA” next to the drug name) is required, and the associated out-of-pocket cost.
• Ask your healthcare professional or pharmacist to check the details of your coverage.
• Call the manufacturer, Eli Lilly, at toll free 1-800-LillyRx (1-800-545-5979) and speak to an agent who can help verify coverage details for Zepbound under your plan.
• Check coverage details on the Zepbound website.

Keep in mind that coverage can change over time so it’s important to check regularly. UHC may also send periodic email or mail notices about changes in coverage.

What to do if United Healthcare won’t cover Zepbound

If United Healthcare doesn’t cover Zepbound, you may have to pay out-of-pocket for the medication. According to the manufacturer, the list price for Zepbound is over $1,000 per month. However, you can pay significantly less if you are eligible for the Zepbound Savings Card. You can also consider these options:

1. Consider Zepbound alternatives: Some plans may cover other weight loss medications. Speak with your healthcare provider if there are other weight loss drugs covered by your UHC plan. These are examples of other weight loss drugs:
   • Saxenda (liraglutide)
   • Wegovy (semaglutide)
   • Qsymia (phentermine/topiramate)
   • Contrave (naltrexone/bupropion)
   • Xenical (orlistat)
2. Consider paying out-of-pocket for the medication: If Zepbound (tirzepatide) is the best treatment option for you, you can decide if you’re willing to pay out-of-pocket for the medication, without using insurance. Without insurance, the cost of Zepbound is around $1,000 per month. However, if you’re eligible, you can pay as low as $650 for a 1-month prescription when using the Zepbound Savings Card.
3. Research other insurance plans: Open enrollment periods (OEP) are typically from Nov. 1 to Jan. 15 in most states, and yo may consider switching to another insurance plan that provides coverage for Zepbound.

How to save on Zepbound

If your United Healthcare plan doesn’t cover Zepbound, there are other ways 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.

Prescription discount cards

If you are paying out-of-pocket without using insurance, you can obtain additional savings on Zepbound by using prescription discount cards offered by companies like GoodRx, Optum Perks and SingleCare.

Single-dose vials

LillyDirect offers the lower-strength Zepbound 2.5 mg and 5 mg single-dose vials in the lower-strength dosages at lower prices than many other weight loss medications.

Compounded tirzepatide

As Zepbound is currently on the FDA Drug Shortages list, you can purchase compounded tirzepatide which contains the same active ingredient as Zepbound and Mounjaro.

Speak to your healthcare provider about potential alternatives

Healthcare professionals can offer medical advice and recommend different treatment options if you have cost concerns. They may prescribe a different weight loss medication that is similar but less expensive than Zepbound.

Bottom line

Most United Healthcare (UHC) plans don’t cover weight loss drugs like Zepbound but there are other ways to save on this medication.

If you are unable to obtain coverage for Zepbound, you can speak to your doctor about potential alternative medications that are less expensive including compounded tirzepatide or check if you are eligible for the manufacturer’s Zepbound Savings Card which provides additional savings.