What if you get denied a prescription for Zepbound (tirzepatide)?

Insurance coverage for Zepbound® may be denied for several reasons:

‍1. The medication requires a prior authorization.  A prior authorization is essentially a form that your medical team completes to answer questions related to the use of this medication and to ensure that it is medically appropriate and necessary for you to be taking it. A prior authorization does not guarantee coverage as medications that are not a covered benefit will not be covered even if you meet clinical criteria. Zepbound and other injectable weight loss medications are quite expensive and often require prior authorizations for coverage.

2. Anti-obesity/weight loss medications are not a covered benefit. Zepbound is FDA-approved for weight loss in adults with a BMI of 30+ or 27+ with a weight related medical condition such as high blood pressure or prediabetes. 

3. Some insurance plans do not cover any weight-related medical care, including prescription medications. This typically depends on insurance benefits selected by your employer and is not related to the insurance company your plan is with. To see if a medication is a covered benefit, you may be able to view your plan’s drug formulary or call your insurance company to speak with someone directly.

4. You do not meet the clinical criteria required for coverage. Some insurance plans only cover weight loss medications like Zepbound if certain conditions are met.  For example, you must have a BMI above a certain level you need to have proof that you have participated in a intensive lifestyle program consisting of a low calorie diet, increased physical activity and behavior change for at least 6 months; or you need to have already tried and failed or be unable to take other lower cost weight loss medications on the formulary first
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5. If your medication was previously covered, but now you are being told it is denied this could be due to several reasons. The simplest is that a prior authorization renewal is required. Other reasons could be that your insurance formulary has changed and the medication is no longer a covered benefit or you did not meet the target of 5% weight loss after 3 months on the medication.