Obesity remains a significant problem in America today. More than half of the country’s population is considered overweight or obese, and this number is rising. However, that appears to be changing thanks to the introduction of popular weight-management medications.
Zepbound is one medication that many people are using to get their weight under control. This medication mimics hormones naturally produced by the human body. These hormones are responsible for appetite control and blood sugar control. Individuals who have not yet tried this medication may be interested in learning more. However, they would like to know whether they have zepbound insurance coverage. Many individuals do not have the money to pay for this medication out of pocket.
Coverage varies by the individual’s insurance plan and where they live. The best way to determine whether a person has a plan that covers this medication is to contact the insurer directly. However, the following information will give them an idea of what to expect when they contact the insurer.
What is Zepbound?
Zepbound is a medication approved by the FDA for chronic weight management in adults who are overweight or obese. This drug is available as an injection and reduces the individual’s hunger. Furthermore, it alters the way the body processes food. Individuals with a BMI of 30 or higher are eligible to receive this medication. If an individual has a BMI of 27 or higher and high blood pressure or another related medical condition, they may also be eligible for this medication. They need to inject the medication weekly, change their diet, and exercise to see the best results.
Individuals find that they will lose weight with this medication. However, it does not happen overnight. They must be committed to long-term medication purchases to achieve the best results.
In addition to the plan an individual has, the reason they are requesting coverage for this prescription determines whether the insurer will pay for it. Each plan determines what it will cover and why. One plan might cover this medication for weight loss. Other plans will only allow it to be prescribed if a person has been diagnosed with diabetes or sleep apnea. Given the many differences among insurance companies, it’s no wonder people are confused about whether they will receive coverage for this medication if their doctor prescribes it.
Private Insurance
Men and women who have private insurance through a company such as Aetna or Blue Cross must contact their insurer directly to learn what is covered under their specific plan. The plan will dictate which medications are covered. Furthermore, the insurance company determines whether prior authorization is required. If a plan will cover this medication, the individual’s doctor must provide the insurer with information such as past treatments the patient has tried and the patient’s current BMI. The patient will likely also be required to pay a copay, which can run into hundreds of dollars a month. At times, the insurance company will deny coverage, and the doctor will need to appeal this denial. They must explain why the medication is medically necessary to see if the insurance company will reconsider its decision and cover it.
Medicare
Men and women who are on Medicare will find that this government program does not cover the medication for weight loss alone. Anti-obesity drugs are not allowed under federal law if a person has a Part D plan. However, if the individual has a medical condition, such as a cardiovascular condition that would improve with weight loss, Medicare may cover the cost of the medication. A senior may wish to pay for this medication out of pocket, but they may find it exceeds $1,000 per month. They should look into manufacturer savings programs to see if they can reduce this cost.
Medicaid
Individuals on Medicaid will need to check their plan to see if this medication is covered. Each state determines its Medicaid coverage, so there is no single answer to whether the government program will pay for it. If the individual has a fee-for-service program, they will find that only about 15 states cover weight-loss medications. Managed care programs might be more inclined to cover the medication, but the individual must meet specific qualifications. For example, a diabetic is more likely to find that Medicaid will cover this prescription than one who is requesting it strictly to lose weight. An individual should contact their state Medicaid office to learn what is covered under their plan.
Employer-Sponsored Plans
Slightly over 1/3 of employer plans today cover GLP-1 drugs such as Zepbound. However, they typically only cover these medications if the individual has a high BMI or has tried other weight loss methods with no success. An individual typically needs prior authorization before their medication is covered. If the plan covers this medication, the copays are typically affordable. If it does not, an individual may wish to look into other plans during open enrollment.
Determining Whether Zepbound is Covered
A person can determine whether their plan covers this medication by reviewing the formulary online or in the member portal. These resources provide information about covered drugs and tiers. If this information cannot be found, the next step is to contact the insurance provider. The physician’s office may be able to assist with determining coverage for this medication.
Lowering Prices
Eli Lilly, the maker of Zepbound, recently announced it will lower the cost of its weight-loss drugs. It is doing so to make the drugs more affordable for individuals who do not have insurance coverage or find that their plan will not cover the cost of the medication. However, individuals must realize that this is a long-term solution for weight management and budget accordingly. This medication is not one they will take for a few months and then discontinue.
As previously mentioned, obesity is a significant concern in America. Insurance companies recognize this, but many do not cover weight loss medications today. A person must learn what their plan covers and how much their co-pay will be when determining whether Zepbound is right for them. Hopefully, this will change in the future, and every person who wants to use weight loss drugs can do so to better their health and well-being in the long run.